Peaceful acceptance of cancer; chemo neuropathy; 'slow medicine'
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Two from Cancer:1)First is a paper discussing a scale developed to measure peaceful acceptance of a cancer diagnosis. This comes from the Coping With Cancer Study (previous publication here) and the paper describes the development and some of the validation of their scale ('PEACE') which attempts to measure both 'peaceful acceptance' of an illness (e.g. asks things like To what extent do you feel you have made peace with your illness?) and 'struggle with an illness' (asks about what extent a patient feels their life is over as they now know it, what extent they feel it's unfair they have cancer, etc.). They also give some ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - May 8, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
How to choose a hospice - updated
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Over the next few weeks I will be publishing an updated set of posts on how to choose a hospice. This is a series I posted first in March of 2005. The format will remain the same and much of the content will remain the same. My thoughts on some issues have changed over the past couple of years (I may have even been wrong about a few things.) and the industry has changed quite a bit. I think this series, out of all the rambling I have done, is probably the most important, so I wanted to try to keep the series updated to the current trends in hospice. There are also many people reading this blog who didn't read it in 2005, a...
Source: Hospice Blog - May 7, 2008 Category: Palliative Carer Workers Tags: Basics Competition Source Type: blogs
L'envoi by george e. ehrlich
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The following essay was first published in Prognosis: Contemporary Outcomes of Disease, published by Charles Press, 1981. Permission granted from Dr. Ehrlich to reprint on Pallimed.Prognosis is the essence of Medicine. It gives purpose to diagnosis and helps the physician ascertain what might happen and decide what ought to be done about it. It lends rationale to treatment. All therapeutic decisions, the popular cost-benefit ratio, and various equations that determine choices are based on what we understand about prognosis. It is bewildering, then, that prognosis receives only passing mention in the disease descriptions fo...
Source: Pallimed: A Hospice & Palliative Medicine Blog - May 6, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
If you think the price of gas is hurting you…
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The price of gas has been making headlines for a while now, and has become a political football. There are all kinds of ideas being put out there by the President and those who want his job. We could have a gas tax holiday, drill for our own oil, punish the oil and gas companies, ride our bikes more… In the end I expect that our "leaders" in Washington will probably point their fingers at the other party and do absolutely nothing.I'll stay out of the political side of the issue, and just say that if gas is going to cost $3.75 a gallon, Medicare needs to seriously consider giving rural hospices a little extra money. Every...
Source: Hospice Blog - May 3, 2008 Category: Palliative Carer Workers Tags: Business In the news Source Type: blogs
Evidence and palliative care; hydration reviewed, sort of; opioid antagonists for obd
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1) Over here at Pallimed we’ve been having an off-line conversation about “evidence” for palliative care-related practices, and decided to bring it to our readers. The impetus for the discussion is the publication of two new Cochrane reviews, one on medical hydration in advanced illness and the other on mu-opioid antagonists for opioid-induced bowel dysfunction.Regular readers of Pallimed will know that the three of us are strong proponents of increasing and improving the evidence base for palliative care. We are also very much aware of the difficulty of doing so, especially using the stricter definitions and methods...
Source: Pallimed: A Hospice & Palliative Medicine Blog - May 2, 2008 Category: Palliative Carer Workers Authors: Thomas Quinn, APRN, CHPN Source Type: blogs
Medicare officially begins hospice rate cut attempt
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I have focused quite a bit in the past on the proposed hospice rate cuts, and have probably done a poor job of explaining the different fronts on which this battle is taking place. One of those fronts has heated up quite a bit.The Centers for Medicare and Medicaid Services has now officially proposed a rule change that will change the wage index that is used to figure hospice payment rates. This change, if it takes effect, will be phased in over a three year period and will reduce the daily rate that hospice can bill Medicare. The wage index is different for different portions of the country, so the exact effect for each h...
Source: Hospice Blog - April 30, 2008 Category: Palliative Carer Workers Source Type: blogs
Head & neck cancer; vitamin d; do not 'metuscitate'; more
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Many items....1)From JAMA:First is one in their ongoing series 'perspectives on care at the close of life' on palliative care for patients with head & neck cancer. Besides being a solid review of the topic, as are most of the 'perspectives' pieces, this one stood out for two reasons. It's the most 'supportive care-y' one in this piece, and really reflects a broad perspective of palliative care as not just for the dying (despite the name of the series). The other is this wonderful (and rarely seen in the medical literature) discussion of self-image and blame:Although some patients may blame themselves and feel they caus...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 30, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
How to submit a presentation for a medical conference
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Submitting a presentation to a medical conference can be a daunting task. It can be so intimidating many qualified people feel they should not even bother, because who are they to 'act' as experts in the field. Or one may have been rejected in the past and figured the odds are against you, so don't bother making an effort again. Others just enjoy going to the conference and not having to 'work.'Well, I want to encourage you to submit a talk. If more people submit talks, an increased variety of talks can be selected. If more people submit talks, new viewpoints can be heard. If more people submit talks, new leaders can emerg...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 28, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
"i wanna be a dnr" and other goodness from the web
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Since it is Friday, let's have a little fun. Here are some palliative care related links and highlights from the web.A ICU Nurse and some colleagues rewrote the lyrics to the popular Nickelback song "Rockstar" to emphasize how some patients may feel in the ICU. The video itself is just the lyrics. Here is hoping she puts together more song parodies and maybe a video or two. (Hat Tip: KPW)If you cannot see the You Tube vide, then click on the post title to hear the song on the original post.If you go to the original You Tube page and read the comments for how many medical professionals feel about this song.BMJ has selected ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 25, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Crying doctors? how to be a good palliative care doctor
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This is part one in a planned ongoing series of how to be a palliative care doctor. Why doctor and not nurse or social worker? Because I am a doctor, so I can only speak of what I know, but some of the same ideas probably apply regardless of discipline. If someone wanted to submit this from a SW or RN or other perspective, I would be willing to guest post it here.The New York Times published an essay by a frequent NYT contributor, physician Barron Lerner about the role of emotions in caring for patients. As one may imagine the piece had much to do with working with patients diagnosed with cancer, and those who were dying, ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 23, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
My hospice cap conclusion
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Conclusion:I do not want congress to focus on changing the hospice cap. Instead, I want Medicare to focus more on enforcement of the cap.My reasoning:The government, especially Medicare, is well aware that there is abuse and corruption in the hospice industry, and they will be forced to address it at some point. As best I can tell, they have three opportunities on the horizon to address these problems.The hospice reimbursement issues that are currently before congress. An across the board cut of hospice reimbursement has the ability to reduce the services hospice patients receive. Yes, if you cut the rates deeply, those c...
Source: Hospice Blog - April 22, 2008 Category: Palliative Carer Workers Source Type: blogs
Morphine vs fentanyl vs methadone; more
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1)The European Journal of Pain has a randomized trial comparing long acting morphine with transdermal fentanyl or methadone as the initial long-acting drug in cancer patients. This was a prospective, unblinded study of ~100 Italian cancer patients (mean age ~60 years) who had ongoing moderate to severe pain (mean baseline pain scores were 7/10) on weak opioids. (It's unclear what the baseline opioid use was in these subjects - without the paper explicitly saying so one has the impression that the group doing the study used a standard 'WHO Pain Ladder' protocol and these patients were ones who were having ongoing pain despi...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 22, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Pallimed’s take on the hospice budget cuts
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As you know, I have been trying to raise some awareness about the hospice reimbursement cuts in the proposed federal budget. Christian at Pallimed has jumped on the bus with a post that is much more informative than anything I have written. Make sure and read his post to gain a solid understanding of what the issues are and then do something about it by contacting your congressman. Another good idea that Christian made is that you put in the comments of his post what you have done so that we can begin to see what effect the hospice blogosphere may be having.(It doesn't hurt that Christian says a lot of nice things about me...
Source: Hospice Blog - April 17, 2008 Category: Palliative Carer Workers Source Type: blogs
Hastening death vs palliative care; preventing aspiration; more
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I am writing this on my front porch as it gets dark - it appears spring is finally arriving to the upper Midwest! I will likely be posting a little less frequently than usual the next couple of months - among other things the 4th baby to be born to a Pallimed contributor since the inception of the blog is heading my way next month and my quiet evenings blogging are fading away for a while.Today is National Health Care Decisions Day, which I'm sure is a good thing, but as Christian pointed out to me why did it have to come the day after Tax Day? Do 'death & taxes' need to be so closely aligned on our national calendar a...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 16, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Some highlights from the web
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Nothing too hard hitting in this one, those last two posts wore me out. And I like many other fellowship program directors around the country are busy getting our fellowship applications ready for the first round of accreditations due in the next several weeks.The Happy Hospitalist found a picture on Flickr reflecting what he sees on his service. His blog post was then picked up by the WSJ Health Blog. The title of his post was "87 years old" and the caption read: A photo worth a thousand words. Now…. multiply by five. One hospital. One service. One day. Mine. This is American health care. It inspired very different take...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 14, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Medicare hospice cuts:is hospice worth protecting?
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Since more than 83% of hospice care in the United States is funded by the Medicare Hospice Benefit any cuts to the Medicare budget draws attention to the hospice (as well as the palliative care) community. Hospice Guy over at Hospice Blog has done a good job of keeping this issue in the news. Here is how Hospice Guy sums up information from NHPCO: The detail I missed in the president's budget proposal is that he is proposing the end of the Hospice Wage Index. Instead of having a wage index just for hospices, we would start using the hospital wage index. Now, I'm no rocket scientist, but I'm figuring that a wage index is a ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 11, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Specialized palliative care is not effective...or is it?
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Conclusion as that is what most people will look at first before deciding whether to delve in deeper. "The evidence for benefit from specialized palliative care is sparse and limited by methodological shortcomings. Carefully planned trials, using a standardized palliative care intervention and measures constructed specifically for this population are needed." Do you think many people in or out of the field of palliative care would read this and have the feeling palliative care may not be effective and therefore is not worth the investment?Well if I were trying to figure out whether to include palliative care in my health c...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 10, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Nhpco legislative campaign
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I've written a bit recently about the Medicare hospice payment changes proposed in the president's budget, and now NHPCO has a tool to help you let our legislators know about your feelings on this issue.If you are like me, the effort you must go through to write your Senators or Representative a letter about any subject isn't worth the minuscule impact that the letter will have. Seriously, do you really think your senator is going to read your letter and change their mind based on what you say? Maybe I'm jaded, but I don't really think my elected officials really care what I think.With that in mind, NHPCO has made it much ...
Source: Hospice Blog - April 9, 2008 Category: Palliative Carer Workers Tags: Medicare Business Quality In the news Source Type: blogs
Lectures about death at yale and carnegie mellon
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In perusing some of the great (and not-so-great) general education resources from colleges and universities, I stumbled across a philosophy course by Professor Shelly Kagan on Death. Dr. Kagan has written a book called Normative Ethics, which is the study of what is ultimately right and wrong rather than what we believe to be right or wrong. If that doesn't confuse you then this free course might be right up your alley. (There is another session from Yale on Intro to Psychology for those who need a little brushing up.)The course was originally recorded in the Spring of 2007 and the 26 hour-long sessions are available in mp...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 6, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
The hospice sky is falling!
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I can't believe I haven't written anything in a month! To make it even worse, it has probably been the busiest month in the industry since I started writing this a few years ago. While it seemed everything hit hyperdrive within the industry it also hit hyperdrive in my life. Wow.It is almost midnight as I write this, so I'm not even going to attempt to give any type of detail to the things that have been going on. Thanks to all of you who have sent e-mails recently asking my opinion on subjects or making sure that I hadn't missed any of the big news. I've been keeping up with the news, but haven't been able to keep up with...
Source: Hospice Blog - April 2, 2008 Category: Palliative Carer Workers Tags: Medicare Business In the news Source Type: blogs
Leukemia & icu prognosis; more
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1)Cancer has a retrospective study looking at prognosis of patients with acute leukemia admitted to the ICU. It looks at all patients with acute leukemia (in any stage of their illness as long as it was pre-transplant) admitted to the ICU at a single institution over a 4 year period - 90 patients in all, mean age ~54 years, almost all had AML. Mortality up to 12 months was measured.Major findings: ICU mortality was ~57% with another 11% dying that hospitalization prior to any treatment for leukemia (out of the ICU). A few percent recovered, were treated, then died. Only 27% survived to hospital discharge; 6 and 12 month su...
Source: Pallimed: A Hospice & Palliative Medicine Blog - April 2, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Pain crisis; cure & heal; the dreaded “d” word.
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1]In JAMA’s ongoing series “Perspectives on Care at the Close of Life,” the Memorial Sloan-Kettering team tackles the management of acute cancer pain crisis.This is definitely one for the Teaching File. As always in this series, a fairly graphic or complicated case is presented with definitions, descriptions, prescriptions, strategy, and philosophy interspersed. I’ll list the salient points:Pain crisis is “an event in which the patient reports pain that is severe, uncontrolled, and causing distress for the patient, family members, or both.” Pain crisis can occur anywhere in the disease trajectory. Pain crisis i...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 31, 2008 Category: Palliative Carer Workers Authors: Thomas Quinn, APRN, CHPN Source Type: blogs
Dcd & not hastening death with opioids
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1)The American Journal of Transplantation has an interesting article about predicting rapid death in a donation after cardiac death (DCD) setting.Context: DCD is a technique of obtaining organs for transplantation in non-brain dead patients. In brain dead patients you can obtain presumably well-perfused, healthy organs from a patient while their heart is still beating as they are considered dead once they are determined to be brain-dead. There are some circumstances however - usually in patients with severe brain injuries but who aren't brain dead - in which life support is stopped, the patient is kept comfortable, and if ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 27, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Pregnancy and palliative care
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If one was to talk about fields that no one would think would be related in medicine, obstetrics and palliative care seem to be worlds apart, but two recent articles make it clear these fields are not that far apart. In the first, an editorial from the Journal of the American Board of Family Practice, titled "Pregnancy care: an apprenticeship for Palliative Care?" (free PDF) the author defines how the beginning of life and end of life require similar approaches from the medical field.When I read the title, I immediately recalled the wise words of a resident who rotated with me at Kansas City Hospice about how the unpredict...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 24, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Pediatric palliative care; 'continuous deep sedation'
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This study attempts to validate the ARS (which was developed relatively empirically based on pharmacologic know-how) in a geriatric population (geriatric clinic patients) by looking at risk scores with actual symptoms and comparing geriatric patients with general primary care clinic patients (on the assumption that older patients are more likely to suffer anticholinergic toxicities). Essentially they found that the AR scale & score were decently predictive of toxicities, particularly in the elderly, and they conclude that the ARS is a reasonable way of identifying high-risk patients. (There is a table with the risk sca...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 22, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Oregon's death with dignity annual report 2007
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2008 marks the 11th year of the nation's first physician-assisted suicide (PAS) state law, also known as the Death With Dignity (DWD) Act. Every year by law, the Oregon Department of Health Services releases an annual report and characteristics of the patients who died and received prescriptions for the intended self-administration to hasten their death.The summary of the 2007 annual report is now available for pdf download as well as the supplementary data and all annual reports from the Oregon DHS website. Since this may hit the news and your patients and colleagues may ask how this relates to palliative care where you p...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 19, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Book review: final exam: a surgeon's reflections on mortality
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Witnessing so much death and illness plays a large role in the informal curriculum of who physicians eventually become as professionals. During our medical school and residency years physicians are influenced greatly by volume, intensity and often times sporadic support received in caring for dying patients. Thankfully this hit or miss approach is changing, but slowly. The inclusion of palliative care in the curriculum of many medical schools and the growth of palliative care physicians to lead as mentors to students, residents, and other attending physicians in approaching death in a more supportive, helpful and person-ce...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 17, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Interview: final exam author pauline chen, md
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Dr. Pauline Chen, author of Final Exam: A Surgeon's Reflections on Mortality, now available in paperback, took some time to answer a few questions from Christian Sinclair and some Pallimed readers. (Click here for the Pallimed book review.)Sinclair: Self-care is a common concern with palliative care professionals, especially as a valuable tool to prevent burn-out with the large emotional toll we face. As you discuss in your book, surgeons in training now have less time to spend in the hospital with the 80-hour workweek, and therefore are likely to spend a higher percentage of time in the OR instead of at the bedside. With ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 17, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
We don't have to feel the pain; more
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This study measured what they called 'vicarious' empathy:Sociologists and psychologists have divided the concept of empathy into two main definitions or types: vicarious and imaginative. Vicarious empathy is an individual's vicarious emotional response to perceived emotional experiences of others and imaginative empathy is an individual's ability to imaginatively take the role of another so as to understand and accurately predict that person's thoughts, feelings and actions. The first definition reflects an innate emotional response, that is, a gut reaction, and is equivalent to the empathic concern described by Davis; the...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 14, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Unacceptable causes of death & other web highlights
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The web has been quite bountiful with small tidbits that relate to palliative care and I wanted to share some of these interesting links.Stumbled across this photo that could be very misunderstood by people who are not familiar with completing death certificates. It is very easy to read this as "dying by the following means are unacceptable", but anyone who has filled out a death certificate knows the coroner/vital records wants a more definite cause, and these terms are interpreted to be vague. (Found via BoingBoing) There is a Fast Facts on "How to complete a death certificate" for a quick review.A lot of blogs seem to b...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 12, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Resuscitation guidance in the uk; suffering for nurses; to sit or not to sit?
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1)If you are not already a regular visitor to palliativedrugs.com (free registration required), this would be a great time to dip into the Bulletin Board. They are having an excellent conversation about the various indications for and ways to order (or not) DNR, DNAR, Allow Natural Death, etc. I don’t think POLST is in the lexicon, but that’s the case in most of the US, too. The thread actually started in November, shortly after the publication of Decisions relating to cardiopulmonary resuscitation: A joint statement from the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 10, 2008 Category: Palliative Carer Workers Authors: Thomas Quinn, APRN, CHPN Source Type: blogs
How to cite a blog nlm mla apa (better?)
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Since blogs are a fairly new medium, there are few standards out there on how they relate to the 'old media,' especially when you consider the world of academics and medicine. Blogs are ephemeral much like journals; they reflect a point of view at a certain place and time. They do not necessarily have rigorous editorial standards or the same degree of permanence or authority as journals. They may be considered less authoritative then a formal presentation, although many formal presentations are two parts opinion to one part fact. Regardless of where a blog post lands on the authority or importance scale, if you ever wanted...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 7, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Spinal cord compression; copd prognosis; more
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Briefies, in no particular order:1)JAMA has a 'clinicians' corner' piece about spinal cord compression. It is a practical, chatty, overview of the topic and a good one for the teaching file. It discusses the controversies surrounding optimal glucocorticoid dosing as well as who should get surgery. The tone and focus of these clinicians' corner pieces tends to be patient-centric, and this one exemplifies that: it confronts the topic from a patient's perspective, and it's always refreshing to see this in such medical literature.An excerpt from the prognosis section:Median survival after spinal cord compression depends on the...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 6, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Two weeks of life - a memoir; placebo jama study
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1)Author Eleanor Clift has written what looks to be a fine book titled: Two Weeks of Life: A Memoir of Love, Death and Politics. (Not related to the recent film Two Weeks) USA Today featured her book which contrasts the private dying experience of her husband and the public experience with Terri Schiavo. The book features some writings from her husband, Tom Braziatits, as he reflected on his illness. The USA Today article does a splendid job not perpetuating any hospice myths, and Ms. Clift (on the National Hospice Foundation board) has some wonderful quotes in the article. her are just a few that capture her hospice exper...
Source: Pallimed: A Hospice & Palliative Medicine Blog - March 4, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Pallimed 2008 annual survey results
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Thanks to all the readers who took our survey at the end of January. As promised we wanted to share some of the results with you as 'payment' for taking the survey.We had a pretty good response for a voluntary survey. Of the 600+ readers at the time of the survey we received 87 surveys for a 15% return rate. So next year we are aiming for 25%! Thanks to all of you who participated, we appreciate your input.88% of responders were in the medical field and 75% of those worked in hospice and palliative care primarily. Figure 1 is the distribution of disciplines. I am pretty surprised we did not have more fellows answer, since ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 29, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Hospice in the federal budget - revisited
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I wrote a quick post earlier this month about the budget proposal that President Bush sent to congress. On first look, it was a little worse for the hospice industry than last year's proposal, but not a big deal. Well, your lowly hospice blogger missed something big in that post. Before telling you what I missed, I'd like to say that this is the precise reason that I encourage you to become a member of the National Hospice and Palliative Care Association. That little portion of the submitted budget that I overlooked is much more than a little issue, and I would have never known about my oversight if it weren't for the aler...
Source: Hospice Blog - February 27, 2008 Category: Palliative Carer Workers Tags: Medicare Business NHPCO In the news Source Type: blogs
Antibiotics and treating infections in the elderly
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This study was part of a larger study called CASCADE (Choices, Attitudes and Strategies for Care of Advanced Dementia at the End-of-Life). (Take that cardiologists with all your fancy acronyms!)The mean number of antibiotic courses per resident was 4 (range 1-20!), and about 66% of the 214 received at least one course with the majority of residents receiving a course within the 14 days prior to death, indicating the effectiveness of antibiotics to cure an infection in advanced dementia may be limited. This multi-center prospective cohort is probably the best study to demonstrate the limited efficacy of antibiotics in patie...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 27, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Reasons for pas; prognosis in tbi; more
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I'm traveling the rest of the week & this will be my only post until March, which I'm hoping will host fewer record-breaking snowfalls in the upper Midwest than January and February have.1)The Journal of General Internal Medicine has an article about family perceptions of why their loved ones pursued physician assisted suicide. It involved interviews of ~80 patients who had pursused PAS in Oregon (about 50 actually received prescriptions and 30 went through with ingestion of the lethal prescription). Family members were interviewed between 3 months and 3 years after the patient died. It's somewhat unclear to me how the...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 25, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Pediatric palliatve care barriers; palliative med salaries
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1)Pediatrics, the journal of the AAP, occasionally features palliative care issues, so when my wife's copy arrives I usually take a quick look at the table of contents. In the February issue they feature an article on the Barriers to Palliative Care for Children as perceived by health care providers. Davies et al polled all staff members (698) at UCSF Children's Hospital, and reviewed the results from the 117 nurses and 81 physicians who replied. Of the remaining 42 respondents they were from other disciplines and there were not enough to make significant comments as a group. The majority worked in NICU and PICU where you...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 20, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
Genetics and morphine toxicity; prognosis articles
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This study looks at those patients who were alive at 6 months and sees if their functional status at that point predicts prognosis. Not surprisingly, it does: the most disabled patients who made it 6 months had a median survival of 2.5 years; those patients who weren't functionally dependent had a median survival about 6 years; functionally independent patients lived ~10 years. (They used Rankin Scores to define disability). (Source: Pallimed: A Hospice & Palliative Medicine Blog)
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 19, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Gao report on end-of-life care; oxycodone review; problems with duragesic and oxycontin
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1)End-of-Life Care: Key Components Provided by Programs in Four States is a report commission by Sen. Ron Wyden. Using descriptions from last decade’s IOM Report and a 2004 AHRQ study, as well as interviews with NHPCO and NAHC, and interviews with 10 EOL researchers, GAO identified 6 “key components” of end-of-life care. Care management to coordinate and facilitate service deliverySupportive services for individuals residing in noninstitutional settingPain and symptom managementFamily & caregiver supportCommunication among individuals, families, and program staffAssistance with advance care planningThey then visi...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 16, 2008 Category: Palliative Carer Workers Authors: Thomas Quinn, APRN, CHPN Source Type: blogs
Confused about dnr's in time magazine; nyt on assisted suicide
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1)This past week has had two fairly prominent major media articles focusing on significant end of life issues. In Time Magazine, Dr. Scott Haig (an orthopedic surgeon) writes about the difficulties physicians encounter when contemplating the appropriateness of Do Not Resuscitate (DNR) orders. (Or more appropriately Do Not Attempt Resuscitation, since we cannot promise any guarantees.) Dr. Haig has written a few pieces for Time before, one of which we noticed here at Pallimed about the VAS for pain being inadequate.In this recent Time article, Dr. Haig reviews the case of an elderly Italian woman (described as spooky, wacky...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 12, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
The 'imminence condition'; phn; more
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1)2 from Journal of Medical Ethics:First is one on terminal sedation and the 'imminence condition'. It's a difficult-to-summarize paper whose main point seems to be that the 'imminence condition' (continuous sedation to unconsciousness without fluids/artificial nutrition is OK as long as the patient is imminently dying and so withholding sustenance is unlikely to hasten death by much), which is endorsed by some proponents of TS, has not been fully explored in the literature and is full of holes (ethical analytical holes, you know the type). Never one to avoid whacking my clinician's head over an ethical analysis, the major...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 11, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Hospice recommendations in president bush's budget
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Excuse me if I'm not up in arms about the new budget proposed by President Bush. I thought about cutting and pasting my post from almost exactly 365 days ago here, because the proposal is largely the same.When President Bush sent his proposed budget to congress, it called for a zero percent rate increase for hospice in 2009-2001. In 2012 & 2013 we would get our normal rate increase minus .65%. Now, going three years with rates not changing at all would be a big deal. I can promise my employees will be expecting pay raises in 2009, 2010, and 2011. Employee salary is often around 80% of a hospice's costs, so giving every...
Source: Hospice Blog - February 8, 2008 Category: Palliative Carer Workers Tags: Medicare Business Quality In the news Source Type: blogs
Symptoms in dying ltc patients; more
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Too many items noted too briefly:1)A few from the Journal of the American Geriatrics Society:First is a paper looking at the symptom experience of dying long-term care residents. This was a multi-institutional study involving interviews of family and staff caregivers of deceased LTC residents (~670 patients, mean age 85 years, most cognitively impaired). Pain and dyspnea were significant in about half the patients prior to death: and significantly while almost all patients had meds for pain about a third had none for dyspnea. The most commonly reported symptoms were issues surrounding cleanliness. From a research perspecti...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 7, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Tom hoyer & the hospice cap
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Briefly, I wanted to mention a section of the gaming portion of the article I've been writing about that I skipped. It is the section on the Medicare Hospice Cap. (My earlier posts on this article are here and here.)Mr. Hoyer does not devote a lot of time to the cap, but what he says is priceless. First, let's review his credintials. He, as a CMS employee, was the person in charge of drafting the original hospice medicare regulations. If anyone on the face of the earth knows what the original purpose of the cap was, it is Tom Hoyer. With that in mind, we'll look at a couple of quotes. "The cap was introduced by hospice's i...
Source: Hospice Blog - February 4, 2008 Category: Palliative Carer Workers Tags: Medicare Business In the news Source Type: blogs
Race and hospice revocation; copd; nabilone for pain; much more
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This is my first post for a couple weeks and I have amassed a large backlog so my next few ones will likely focus on a single article and then mention others only in passing.Thanks for everyone who said Hi in Tampa, or who came to the happy hour (M. sorry about the loud music - it's too bad Wham! is not your cup of tea). Tom Q - we missed you.A quick note about the Blogging on Peer-Reviewed Research and Research Blogging system that we have alluded to before. The Research Blogging website is now officially up and running. It is, among other things, an aggregator of all blog posts by bloggers who use the BPR3 standards - i...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 4, 2008 Category: Palliative Carer Workers Authors: Drew Rosielle MD Source Type: blogs
Back from the aahpm /hpna in tampa
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Drew and I appreciate all of the wonderful feedback we received while in Tampa at the AAHPM/HPNA Annual Assembly last week. Thanks to all the readers who proudly wore the "P" sticker and who came to Backjack's to meet with other Pallimed readers. It was good to match faces to names. If I missed you there or didn't have much time to chat, I apologize. For being there less then 24 hours it was quite an exhausting pace.We heard a lot of interesting comments about the conference as well. I wished I could have made it to more than just the Case Conferences on Saturday (which were great BTW). So to make up for all of my lengthy ...
Source: Pallimed: A Hospice & Palliative Medicine Blog - February 4, 2008 Category: Palliative Carer Workers Authors: Christian Sinclair, MD Source Type: blogs
