Literature Potpourri

by: Alex Smith, @AlexSmithMD

Ronald Reagan died in 2004 of advanced dementia

Some great paper GeriPal readers should be award of published recently:

1. In the Journal of Pain and Symptom Managment, Harvey Chochinov calls for action on dignity conserving care.  He argues for just 20 minutes of dedicated time four times a year to reflect on the subject of caring, using brief videos as prompts (a very GeriPal concept).  Here is an excerpt, “Formal education for healthcare providers lacks a continued focus on achieving a culture of caring. If caring really matters, healthcare systems can insist on certain behaviors and impose certain obligations to improve care tenor, empathy, and effective communication….Healthcare professionals must set aside some time, supported by their institutions, to advance a culture of caring—now is the time to take action.”
2. Opioid prescribing for chronic pain is a hot topic – see this New York Times article about the forthcoming FDA restrictions on Vicoden prescribing, restrictions opposed by the American Cancer Society.  In a perspective in the most recent Journal of General Internal Medicine, Daniel Alford argues for a more scientific approach to opioid precribing.  He proposes greater study of patient-doctor communication about efficacy, risks, and benefits.  He notes that, “Unlike other chronic diseases where specialists are available to co-manage complex cases, currently there are not enough pain and addiction medicine specialists. Therefore, primary care providers are often left to manage some of their most complex patients without adequate support from experts.”
3. When nursing home residents with advanced dementia are discharged from the hospital, the nursing home has a strong financial incentive to bring them back under the Medicare Skilled Nursing Facility (or SNF – pronounced “sniff”) benefit.  The SNF benefit payment is much higher than the daily Medicaid long term care payment.  Is this a problem?  Jane Givens finds in the most recentJournal of the American Geriatrics Society that over 60% of hospitalized nursing home residents with advanced dementia are discharged on the SNF benefit!  The major predictor was feeding tube insertion during the hospitalization.  Patients from profit nursing homes were more likely to be admitted on the SNF benefit after hospitalization than not-for-profit nursing homes.  Hmmm….link the chain together and you get a perverse financial incentive to admit patients with advanced dementia to the hospital to have a feeding tube inserted, then have them readmitted to the nursing home under the SNF benefit.  Not proven, but kinda smells, doesn’t it?
4. Sticking with advanced dementia, this same issue of the Journal of the American Geriatrics Society, Laura Hanson finds that weight loss is the major predictor of mortality in nursing home residents with advanced dementia and feeding problems.  As usual for advanced dementia, there were both strong patterns and considerable variation.  Residents with weight loss over 3 months had a 19% chance of dying; they also had a 39% chance of stabalizing weight.  In contrast, those with a stable weight had only a 2.1% risk of death over 3 months.
5. This issue of Journal of the American Geriatrics Society should be subtitled, “The GeriPal issue!”  Livia Anquinet writes in this issue about a series of 11 nursing home residents with dementia who received palliative sedation in Belgium.  Despite use of “continuous deep sedation” nurses reported that the last 6 hours of life were a struggle for three patients.  Was the sedation not “deep” enough?  Or, perhaps, palliative sedation was not the best mode of treatment.

Happy reading!