Palliative Care Grand Rounds

Welcome to Palliative Care Grand Rounds! This monthly blog carnival highlights some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. As this month’s host of Palliative Care Grand Rounds, we will give our own “GeriPal spin,” incorporating posts that feature the intersection between geriatrics and palliative care. Topics are sorted by heading. Thanks to our readers for suggesting posts. Have fun reading!

Death Panels and Health Care Reform
The saddest part of September came when the Advance Care Planning Consultation proposal (section 1233 from the house bill) was dropped due to concerns about “Death Panels.” This was despite hard work from many members of our community including:

• The AARP, which had a great article on the politics of advance care planning and how section 1233 was falsely portrayed by fear-mongering. A quote from the article says it all – “Medicare pays doctors for procedures and treatments, but a physician who spends an hour explaining the ins and outs of medical directives cannot currently bill for that time and effort.”
• Gail Austin Cooney, President of the American Academy of Hospice and Palliative Medicine, whoblogged at the Huffington Post about her experience being newly diagnosed with ovarian cancer with a copy of “5 Wishes” on her lap never having filled an advance directive before this crisis. The goal of the article was to reframe the death panel debate and highlight the importance of encouraging physicians and patients to discuss end-of-life preferences when they are “healthy, clear headed and not in the midst of a medical crisis.”
• Christine Cassel, President of the American Board of Internal Medicine, Diane Meier, Director of Center to Advance Palliative Care, Mount Sinai School of Medicine, and Jerald Winakur, Center for Medical Humanities and Ethics at University of Texas, who were interviewed by the journal Health Affairs. Dr. Cassel summed up the debate on section 1233, stating that keeping the advance care planning provision was not worth risking the overall success of health reform. Such is life…
• Evan Falchuk at SeeFirstBlog, who has a nice post about the reasons 73% of Americans think death panels might be real. The reasons: 1) It’s almost impossible to prove something doesn’t exist; 2) No one is reading the legislative proposals; and 3) Not talking about difficult trade-offs, while still making them. Further comments at DB’s Medical Rants.
• Terminally ill patients and palliative medicine physicians interviewed for the online magazine FLYP. FLYP (pronounced “flip”) is the absolute pinnacle of online multimedia – video, text, sound, click everywhere. Slick! Thanks to Pallimed and one of their readers (utzgrrl) for bringing this to our attention.
• Will Ferrell (OK, Will Ferrell is not officially a member of our community, but we would like to welcome him as an honorary member. And this wasn’t as much a defense of the advance care planning legislation as of the public option.). Thanks to the Health Culture for bringing this hilarious video to our attention. In the video, Will Ferrell and other superstars defend the rights of health care executives. Here’s a snippet:
  

  Insurance company CEO’s have a right to their American dream: five houses, a private plane, $500 million in your pocket. And a mini-zoo in your backyard for exotic animals, like a white tiger and pygmy horses.

• Finally, Tim Cousounis at Palliative Care Success blogs about Accountable Palliative Care Organizations. We need his sort of innovative thinking about how palliative care fits into – and can be a model for – health care finance reform.

Futility

• Medical Futility Blog by Thaddeus Pope: one of the best websites covering medical futility issues highlights an important case working itself through the court system – Betancourt v. Trinitas. This is a case of an elderly man in persistent vegetative state dependent upon dialysis, a ventilator, and a feeding tube. His family sued a hospital that was attempting to unilaterally withdraw extensive life support. If you are interested in ethics or end-of-life care, Pope’s blog and his amicus curiae brief is a must see.
• The Hospice Physician’s Blog posted a communicationbetween the blog’s author and an oncologist from theblog cancerdoc. The post focuses around the question, “Why don’t they stop chemo?” It does a nice job of bringing home the challenges seen in end-of-life care from the viewpoints of two different medical disciplines. Well worth the read.

The Power of Pain & Distress

• Dana Jennings from The Well had a great essay on the power of severe pain. Favorite quote: “I’ve found that the deepest pain holds no meaning. It is not purifying. It is not enobling. It does not make you a better human being. It just is.” (For different perspectives on the relationship between physical suffering and meaning, read Eric Widera’s posts/comments on GeriPaland KevinMD about this Lancet article, co-authored by GeriPal’s Alex Smith and Patrice Villars.)
• Also from The Well, Theresa Brown wrote about the moral distress health care providers feel when our interventions result in increased patient suffering.

Forgiveness & Healing

• Risa’s Pieces recently had a post on “Kol Nidre,” a prayer recited on the Jewish holiday Yom Kippur, asking for forgiveness for unfulfilled promises. This post came at the perfect time as one of us (Eric) recently promised a patient he would come back to visit him, but unfortunately the patient died before he fulfilled his promise. Risa acknowledges that her “list of small promises not kept is quite lengthy. In my work-life, people often die before I can do what I hope to do, offer to do, vow to do to make their life a little sweeter.” Further on Risa helps us cope with the line “I will go to shul tomorrow to hear Kol Nidre chanted as it has been done for centuries, bringing past into present, absolving me for being human, imperfect, less than my promises suggest.”
• Confessions of a Young (Looking) Social Worker has a touching story of forgiveness that emphasizes the importance of caregivers.
• Jim deMaine from the End of Life Blog wrote about the death of his mother and the role that an “Ethical Will” played in leaving a positive legacy after her death.
• Death Club for Cuties (love the name!) recounted a story with a very simple message – “that sometimes it’s so important to sit next to somebody in order to actually be with them.” Well said, Jerry.

Care of Complex Older Adults

• Chris Langston blogging for The Hartford Foundation wrote about the Guided Care Project, a nurse-driven primary care intervention with the objective of providing “whole person care” for older adults with chronic conditions and complex health needs. Physicians Langston interviewed were unable or unwilling to acknowledge that the guided care nurse improved care. Sounds like the project needs to be reframed around teamwork. What did Bal Mount say – something like, “You say you’ve worked on a multidisciplinary team? Show me your scars.” The lesson here is that teamwork can be hard, ego-bruising work, but the end result is unquestionably improved care for patients.
• Great quote from this post at ChangingAging about what it’s like to live with dementia:
  

  After living with dementia for six years Dr. Richard Taylor (2007) shared his experience: “Sometimes, when I am alone with my thoughts, I wander aimlessly around the corridors of my mind. I open various doors to see if they are still full of the memories I stored there years ago. To my pleasant surprise, most of them seem to contain all that I remember putting in the room. However, as I move from the past toward the present, I find more and more empty rooms. Not only are they empty, they are dark. They offer no clue, other than the label on the door, as to what they once contained.”

Closing Thoughts: The Art of Medicine and Nursing

• Pallimedhas a tasty review of posts from the blogosphere about all things health, focused on the art of medicine and nursing.

There was so much great material this month! Apologies to those bloggers we missed – post a comment below mentioning your site. Please check the archive website to see who will host next month edition. Thanks to Pallimedfor including us and organizing Palliative Care Grand Rounds!

-Alex Smith and Eric Widera