Palliative Care Grand Rounds 2.9
Sep 1st
Welcome to the monthly edition of Palliative Care Grand Rounds the monthly review of the best of hospice and palliative care content from blogs. We started in February of 2009 and are almost done with our second full year. To see previous editions of Palliative Care Grand Rounds go the http://palliativecaregr.blogspot.com/.
Marten Creek Photo by Joan Robinson RN CHPN Seattle WA
This summer has been a exciting month for palliative care and hospice advocates. At the beginning of the month we were still taking in all the attention form Atul Gawande’s article in the New Yorker titled ‘Letting Go.‘ And then in the middle of August we had the ground breaking research published in the NEJM demonstrating early palliative care improves QOL, reduces depression and potentially can improve survival.
So I thought we could start with blog posts relating to those two big tent poles.
The Gawande Article
People were reflecting on the writing of Atul Gawande and I think there is a lot to learn from how he tells his stories. It may help in how you give a presentation or write articles or blog posts of your own. My favorite was a blog called ‘Not Exactly Rocket Science’, where blogger Ed Yong writes on ‘Deconstructing Gawande – why structure and narrative are important.’ Also check out Bob Wachter’s blog piece on Atul Gawande and the Art of Medical Writing. He writes:
In this month’s piece, Gawande continues to tackle the most important healthcare issues of our day. By doing this with such clarity and beauty, he makes us all a little smarter, wiser, and more sensitive. His writing is a gift.
Debra Bradley Ruder from the GrowthHouse blogs Goodbyes writes on the Gawande article as well.
The NEJM Study
Both Geripal (Alex Smith) and Pallimed (Lyle Fettig) jumped on the NEJM research quickly and provided really helpful insights into the research that you wouldn’t get just reading the New York Times or other media sources. Between these two posts there are currently over 35 comments! Several days later Drew Rosielle let the results marinate with him a bit and the result is a tasty dessert highlighting the implications for our field in his Pallimed post ‘You had me at improves HRQOL.’
Diane Meier jumped into blogging and wrote a good piece at the John Hartford Foundation blog, that was picked up my the (general medicine) Grand Rounds and got 2nd billing. Many other key blogs covered this as well including:
- Center for Practical Bioethics
- Hospice Foundation of America
- AAHPM blog
- Palliative Care Success (good one on applying the results of this study)
- db’s Medical Rants
- Science Codex
- Freeforall – A health policy discussion
- Right Truth – Palliative Care Improves Survival?
- American Cancer Society – Dr. Len’s blog
Other great bits
- Joanne Kenen has done a number of stories on palliative care issues and got a lot of feedback on her piece in Slate magazine about palliative care issues in the emergency room. She had a great follow-up piece with on her blog at The New Health Dialogue about the challenges to why these conversations don’t necessarily happen in a primary care setting.
- You may have heard of a new breed of patients: the e-patient. One of the vanguards in the e-patient movement is Dave deBronkart who recently wrote a book Laugh, Eat and Sing Like a Pig. He published an excerpt on KevinMD that is a must read and made me go buy the book too.
- You don’t see many CEO’s of hospitals blogging and no one does it better than Paul Levy. He had a great post about visitng patients in his hospital and the role of hope that I think many of us could identify with. An excerpt:
Each person faces cancer in his or her own way. There is nothing right or wrong about the different approaches people take. Denial or acceptance is not a statement about someone’s character. Having hope or not does not always come from an explicit decision to be hopeful; it often just happens one way or the other. Likewise, the spectrum from stoicism and strength to dependence and, yes, even weakness, are reactions that are unpredictable until you are actually faced with the disease. Too, how one feels can change over time — whether minute to minute, day to day, or year to year. So, one thing I have learned is not to be judgmental about how a person responds to cancer.
- In another post Paul Levy also discusses the case of the ER staff who took pictures of a dying patient and posted them to Facebook. Obviously this was a dumb thing to do, but people still did it so it begs the question, is this an issue of social media is bad or lack of professionalism? Read ‘Blocking Facebook won’t stop stupidity’ to find out.
- Eric Widera at Geripal noted the findings of the NEJM study may impact how we look at palliative care in nursing homes as well with his analysis of a recent study in the Journal of the American Geriatrics Society. How can geriatricians and palliaticians ( I just made that up) work closer together?
- AAHPM Board member and PC-FACS editor Amy Abernethy (with Donald Taylor) blogs at Health Affairs on End of Life Savings: The Fools’ Gold of Reform. An excerpt:
It is doubtful that a focus on reducing EOL spending per se will result in as much savings as is often assumed, for one simple reason: The concept of the last year of life is inherently retrospective. You do not know when the last year of someone’s life started until it ends. The stylized fact that leads to the assumption of wasteful EOL spending., i.e., 1 in 4 dollars spent on care in the last year of life, is based on an inherently retrospective concept that does not translate easily into the prospective decision-making that would be needed to reduce wasteful, futile or harmful spending in the last year of life.
- The anonymous blogger Hospice Doctor writes about going to funerals and the impact it has on our lives ina ddition to what it means to families. An excerpt:
And then I understood. I wasn’t crying for him. I was crying for me.
I cried because I couldn’t imagine a memorial service for me looking anything like the one for Rob. I cried because I couldn’t imagine that twenty people, let alone two hundred, would give up an evening to say nice things about me. I cried because I couldn’t imagine that my life, already a lot longer than Rob’s, would ever have that kind of meaning and impact. I understood then that my patient’s short life was telling me to live the rest of my own life better — to be warmer, and more open-hearted, and more loving.
- Frances Shani Parker from the Hospice and Nursing Homes Blog found a great video on YouTube from the EPEC-O series featuring Charles Von Gunten on burnout and wrote a post about a recent study from the Mayo Clinic on physician burnout.
- Richard Smith blogs over at BMJ about Contemplating my deathbed and discusses the various regrets people may have and hot make sure you don’t have so many regrets yourself! An excerpt:
people—actually mainly men—wished that they hadn’t worked so hard. They “deeply regretted spending so much of their lives on the treadmill of a work existence.” My wife would say that I work all the time, but I live a life where work and play are not easily distinguished. Is writing this work? It doesn’t feel like it to me. Tomorrow I’m off to give a talk at a science festival in the Austrian Alps. Is that work? The truth is that even in the most serious jobs I’ve always let the appealing (and often frivolous) come before the serious.
Some humor
- Alex Smith from Geripal created this very funny animation about trying to use your great communication skills honed in palliative medicine at home when your spouse asks you to ‘take out the trash.’ My favorite line: “I wish the trash were taken out but unfortunately it has not been”
- Brian Vartabedian of the very excellent blog 33 charts found an old ad for senna that you may want to bring to your next IDT.
- No one likes to say the words death or dying, but we know it is important to be able to convey these messages with honesty and in an individualized manner. Schott’s Vocab at the New York Times asked readers for different ways you could euphemize ‘dying’. I will warn you some are coarse, some poignant but check out some of the 845 comments and counting for ways to say ‘Kick the bucket.’
- And finally we have heard that Oscar the nursing home cat that can predict the impending death of patients has a movie deal based on the book. Let’s hope they get an advisor on the movie who is knowledgeable about hospice.
Oscar the Cat - Photo by Stew Milne of AP.
So as you can see there are many people talking about the difficult things people don’t want to talk about. We are not alone in wanting to provide good quality care for patients and families facing with life-threatening illness. Sometimes with a little humor is a tough time, sometimes with fantastic insights into what it means to be alive. Go read and support the things that impact you with a comment, Facebook ‘like’ or email to a colleague.
Check out next month’s host the SWHPN blog called palliative-sw. They have a new look!
PCGR has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.
Heads up!! Calling all measure geeks!! Save the date: NQF call for measures planned for November 2010
Aug 31st
This post was co-authored by Dale Lupu, PhD and Sydney Dy, MD
The National Quality Forum (NQF) is planning to issue a call for measures relevant to hospice and palliative care some time late in 2010, probably November. This is a critical opportunity to advance quality measurement for our field. (Hopefully, quality improvement follows on the heels of measurement.) Any of you who have submitted measures to NQF in the past know that quite a bit of effort goes into filling out the measure submission form, so we wanted to give you some advance notice as you think about the workload for yourself and your team going into the fall. Once NQF issues the call for measures, you will have 30 days to submit the forms. Here are links to general information on the NQF measure submission and endorsement process:
Every measure endorsed by NQF has to have a measure steward. The measure steward is responsible for making the necessary updates to the measure, and for informing NQF about any changes that are made to the measure on an annual basis. The measure steward is also responsible for providing the required measure information for the measure maintenance process that occurs approximately every three years.
If your organization has developed quality measures that you are finding useful in guiding quality improvement within hospice and palliative care, please consider submitting the measure(s) to NQF in the fall. It is very important that NQF receive a strong and robust set of measures to consider for endorsement. NQF endorsed measures form the backbone of pay for performance and value-based purchasing efforts that will likely impact more and more on hospice and palliative care in the coming years. The field needs a strong set of endorsed measures to move quality improvement efforts forward.
For those of you who fit the category of “measure user” more than “measure developer” – take heart. When it is finished, the results of this NQF project will be an important resource for you. A clear set of NQF endorsed measures in palliative and hospice care will make it easier for you to select and promote measures in your own setting. Begin laying the groundwork now for eventual implementation by spreading the word to the quality gurus in your organization that NQF endorsed palliative care measures are on the way for 2011.
Another indication that HPM is becoming more mainstream?
Aug 25th
In the category of ‘what goes around comes around,’ a recent event reminded me of the ironies life can bring; but this is a cautionary tale for all. At this time last year, I was immersed in a trial. While there is a general impression that hospice and palliative medicine are relatively immune from issues of tort liability and malpractice, this is proving to be increasingly untrue. In some parts of the country, trial lawyers are exploring new theories of litigation with causes of action against hospice and palliative medicine providers, an untapped and fertile ground for potential malpractice awards. While this clearly isn’t “good news,” ironically it may be another milestone in HPM’s ongoing efforts to integrate into ‘mainstream medicine.’
The case involved a middle-aged man who presented with non-small cell lung cancer. At initial diagnosis, disease seemed to be limited. He underwent surgical resection to remove the mass; however, biopsies showed tumor present in the contralateral lung, as was confirmed by subsequent bronchoscopy. After completing radiation therapy, he had two more bronchoscopies, each confirming ongoing malignancy in both lungs. He was referred to hospice when he declined chemotherapy.
His course was complicated by pain, at least in part related to post-thoracotomy syndrome. This required high dose opioids for pain management, after failure of interventional techniques and other adjuvant therapies. While on hospice over the next couple of years, he underwent further diagnostic and prognostic evaluation, including imaging studies showing ongoing progression of disease.
Then something changed. Coincidentally at the time he moved out of our service area, reevaluation by his new treatment team indicated radiographic regression. His performance status began to improve. Believing his prognosis was extending, he was discharged from hospice and his new internist assumed duties as his primary care physician (PCP), including management of his ongoing pain.
Almost two years after his hospice discharge, a suit was filed. Five years after that, the suit finally went to trial. Discovery proceedings showed that his new PCP told this patient that there was an error, and that his cancer must have been misdiagnosed because if he really had cancer in the first place, he would have died. His PCP weaned the patient off opioids (despite ongoing pain) and told him that by giving him high dose opioids when he didn’t have cancer, the hospice and yours truly as the hospice doctor, (though I was eventually dropped as a named party in the suit) had turned him into an addict, which was malpractice.
This theory that we made him an addict then formed the basis for a suit, supported by one board-certified “expert” (a very part-time, hospice and palliative medicine physician from four states away), as well as a stack of articles indicating that opioids cause harm. These studies involved street heroin users, polydrug abusers, or patients with sleep apnea; not individuals being treated under careful medical supervision for severe pain. The defense included several HPM specialists and a renowned pain specialist, all of whom agreed that care was not only appropriate, but exemplary. In the end, this jury of our peers were evidently swayed by plaintiff attorneys theatrics like: referring to the commercial showing an egg frying in the pan with the statement, “here’s your brain; here’s your brain on drugs,”; or pouring out a 50-lb bag of beans over the floor in front of the jury to indicate (without having to prove up the numbers) how many pills the patient supposedly took during his hospice stay. Defense testimony that this represented a rare case of spontaneous remission was met with derision, the implication being that claiming “a miracle” as our defense is really no defense at all. The judge, clearly trying to champion the underdog, made several rulings favoring the plaintiff, which all later agreed would have been adequate basis for a successful appeal and eventual retrial.
When the jury, in its deliberations, began sending out questions indicating that an award was being contemplated, the suit was settled. Defense attorneys wanted to limit a potential high-dollar award, while plaintiff attorneys wanted to avoid the risk of an appeal sending the case back for re-trial. Post-trial juror debriefing revealed that no one really believed anyone had done anything wrong; but, “no one can have cancer like that just go away,” and “the poor man just deserved some sort of compensation for all he had been through.”
Regarding this being a cautionary tale: all medical practitioners should be aware that at trials, our legal system is much more about theatrics than scientific facts. To plaintiff lawyers, this is a business in which they will push all limits in order to win. To defense attorneys, this is about limiting financial risk. To judges, this is often about protecting the poor and unfortunate, even at the expense of those who did nothing wrong other than not being so unfortunate. Sadly, I used to believe what we’ve all been taught: that this is supposed to be about fairness and justice. During this almost three-week trial, I heard much more talk about winning the lottery than about achieving justice.
Ironically, what served as the trigger for blogging about this (if you can believe it), is that last week we received a referral to our hospice for a now slightly older man with terrible pain due to wide-spread, metastatic non-small cell lung cancer. His statement was that he’d had a “bad experience” with hospice once, but now he believed he needed that kind of care once again. Upon legal advice, it was decided to refer him on to a different agency; one that he had not previously sued. I have to admit feeling sad over that decision, since I still believe we treated him correctly the first time, and could again provide him appropriate relief of suffering, during these, his last days. But then again, life isn’t always fair.
Day Two of Intensive Review…
Aug 23rd
The second day was just as intense as the first- fabulous speakers and a review of important information.
Here are some pearls from the second day of AAHPM board review course:
Dyspnea: (Vincent Jay Vanston)
-Total Dyspnea has 4 domains: Physical, Psychological, Interpersonal, Existential
-Must address all domains to adequately control Dyspnea
-When possible and appropriate, treat the underlying medical cause of dyspnea
-Opioids remain the front line agent for symptom relief
-Little support for benzo’s as front line agent
-Benzos and Opioids used together provide best effect when treating dyspnea
Nausea and Vomiting (Joseph Shega)
-Four pathways of Nausea- chemoreceptor, cortex, peripheral and vestibular
-No medications directly affect the Vomiting Center in the brain
-Know what drugs work on what receptors
Anorexia and Cachexia (Jennifer Reidy)
-Multiple factors contribute to ACS: tumor by-products, chronic inflammation, metabolic/neuroendrocrine/anabolic derangement
-Understand secondary causes of ACS (ex: oral problems, psychosocial issues, functional issues)
-ACS also occurs in non-cancer states such as with cardio-pulmonary disease, CKD, liver disease etc
-Understand difference between ACS and starvation
-Artificial Nutrition and Hydration (ANH) is not food, but medical therapy
-Purpose of ANH is not to improve comfort
Urgent Medical Conditions (Jennifer Reidy)
- Bowel Obstruction med management with analgesics, antiemetics and anticholinergics; anticholinergic drug of choice is glycopyrrolate 0.2mg-0.4mg sC Q6H or 0.02mg/hr infusion; drug of choice as it does not cross the BBB
-Spinal Cord Compression med management with high dose steriods; consider surgery +/- radiation therapy- good topic to look up in detail!!
- Seizures: status epilepticus defined as any seizure exceeding 5 minutes OR two seizures in 30 minutes without recover of consciousness- mortality 21-33%! those at risk: brain tumors, hemorrhagic stroke, h/o seizure, alzheimers, alcohol or drug abuse (w/d risk), liver/renal failure, lyte abnl, neurodegenerative dz, infections
-Seizure medical treatment options: subcut midazolam or phenobarbital; rectal diazepam (most antiepileptics can be given rectally); intramuscular lorazepam, midazolam or phenobarbital; sublingual lorazepam, clonazepam or midazolam; intranasal midazolam
Other topics discussed on day two: depression, delerium, other medical emergencies such as increased ICP/ pathological fractures and hemorrhage, palliative sedation, wound care, dementia, advanced cardiopulmonary disease and care of the imminently dying.
Suggested articles:
1. Abernathy A, Wheller J.Total Dyspnea. Current Opinions in Supportive and Palliative Care, 2008, 2:110-113
2. Del Fabbro E, et al. Symptom Control in Palliative Care- Par II: Cachexia/Anorexia and Fatigue. J Pall Med, 2006, Vol9 (2): 409-21
3. Ripamonti C, Mercandante S. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of Palliative Medicine, 3rd Edition. Doyle D, Hangs G, et al., eds. Oxford: Oxford University Press; 2003:8:496
4. Abrahm JL, Fanffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: “All I care about is walking and living my life.” JAMA 2008; 299(8):937-46
5. Stewart AF. Hypercalemia associated with cancer. N Engl J Med 2005;352:373-9
6. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Management 1995; 10:224-32
7. Wood, GJ, Shega JW, Lynch B, Von Roenn JH. Managemetn of intractable nausea and vomiting in patients at the end of life. JAMA 2006. 298 (10): 1196-1207
Other resources:
http://palliativedrugs.com website gives nice medication conversions
My thoughts on the final day at the review course will come shortly….
Tanya Stewart MD FAAHPM
NEJM Study Shows Palliative Care Extends Life
Aug 20th
Most of you have already seen the study released yesterday in the New England Journal of Medicine and I suspect that those of you who work in palliative medicine were not at all surprised by the results: patients who received palliative care along with standard oncology treatment for advanced lung cancer not only had a higher quality of life, but lived three months longer, as well. Isn’t that what we’ve been saying all along?
I have personal experience that supports their conclusions. When I was diagnosed with advanced ovarian cancer in 2008, I relied on a program of palliative care to enable me to tolerate the toxic intraperitoneal chemotherapy that was recommended. I was determined to get ALL of my treatments, WHEN they were scheduled, in order to give myself the best chance of responding. I sought out aggressive symptom management, controlling the pain and nausea so that I could be ready for the next round of treatment. I saw an oncology counselor and set up a website to coordinate meals for my family and me. I prayed. My friends prayed. Friends of friends prayed. I used acupuncture, initially to help with the nausea but later, just because it made me feel better. Three Reiki masters came to my home weekly to keep my energy positive.
And I stayed on schedule! I had chemotherapy the day before Thanksgiving (only because they were closed on Thanksgiving and Thursday was my “usual” day). I finished my last treatment on Christmas Eve. I was determined to do this and palliative care made it possible. With an “n” of one, I’m not a randomized trial, but I did better than those around me. And, I’m still here two years later to marvel at my survival.
But now there IS a randomized trial!
151 patients with newly diagnosed, metastatic non-small-cell lung cancer were randomly assigned to receive either early palliative care integrated with standard oncology care or standard oncology care alone. The primary outcome was the change in quality of life at 12 weeks, assessed by the Functional Assessment of Cancer Therapy-Lung (FACT-L) and the Hospital Anxiety and Depression Scale. Data on end-of-life care were collected from electronic medical records.
Patients who received concurrent palliative care had a better quality of life than did patients who received standard care alone (P = 0.03). They also had fewer depressive symptoms (P = 0.01). At the end-of-life, the palliative care group had fewer aggressive treatments (aggressive care was defined as receiving any of the following: chemotherapy within 14 days of death, no hospice care, or admission to hospice less than 3 days before death) (P = 0.05). Despite this, the patients who received concurrent palliative care from the time of diagnosis lived longer – almost 3 months longer (ll.6 months vs. 8.9 months, P = 0.02).
This study confirms the importance of palliative care begun at the time a serious illness is diagnosed, enabling patients to live better AND to live longer. Great news for patients and for the field of palliative care.
Intensive Review Course is Intense!
Aug 12th
Day one was an excellent and fast paced day in the dungeon of the Hyatt in downtown Chicago. It appears the leaders at AAHPM have mastered Atul Gwande’s “Checklist Manifesto” as everything appeared smooth from the start.
Over 680 participants and close to 300 on the waiting list; thirteen 30 minute sessions with two 30 minute panel discussions breaking up the day; 7 speakers… really, what could go wrong? If anything did go wrong, the cover up was superb.
Now to the content of the course- great refresher and some excellent new information was shared. For those of you not attending the course or those at the course who experienced post-prandial coma and missed some points- here are a few highlights from a couple of today’s lectures:
v Pathophysiology of Pain (Eduardo Bruera)-
- Have a clear understanding of incidental pain and how this is different from treatment of break through pain
- Only area of pain we can measure is “Expression” which has five components: cognitive status, mood, beliefs, cultural, biography
- Have an idea of inhibitory modulators of nociception and excitatory modulation of nociception
v Pain Assessment and Barriers (Michael Preodor)-
- Understand the barriers at the Provider, patient/family, system levels
- Understand difference between addiction, dependence, pharmacologic tolerance, pseudo-addiction and diversion
v Principles of Pain Management (Eduardo Bruera)
- Pain is multidimensional- if pain is increasing, one must do a complete assessment
- Risk factors for developing Opioid Induced Neurotoxicity (OIN)include
- High opioid dose
- Prolonged opioid exposure
- Pre-existing delirium
- Dehydration
- Renal failure
- Presence of other psychoactive drugs
- Diagnosis of OIN
- Cognitive failure
- Severe sedation
- Hallucinosis/ delirium
- Myoclonus/grand mal seizures
- Hyperalgesia/ allodynia
v Pediatric Sessions (Jeanne Lewandowski)
- Start low, titrate quickly
- Half of all pediatric deaths occur in the first year of life, of which half are in the first month
- Unable to declare a child dead by neurologic criteria (brain dead) in the first week of life
- Participation of the ill child in decision making is ideal- term used in “assent”
Articles some of the speakers suggested we read:
- Zisook, S, Shear K. Grief and bereavement: what psychiatrists need to know; Work Psychiatry 2009 June; 8(2):67-74
- Himelstein, BP: Palliatve Care for infants, children, adolescents, and their families. J Pall Med 9(1) 2006, 163-181
- Lo B, Ruston D, Kates LW et al. Discussing Religious and spiritual issues at the end of life: a practical guide for physicians. JAMA 2002; 287(6)749-754
- Cassell EJ. The nature of suffering and the goals of medicine. N Engl J Med 1982; 306:639-45
- Smith HS. Opioid Metabolism; Mayo Clin Proc 2009; 84(7):613-24
- Hanks, G et al. Strategies to manage the adverse effects of oral morphine: an evidence-based report. Journal of Clinical Oncology 19(9); 2542-54, 2001, May
So, we are off to a great start! Let’s see what tomorrow brings….
Tanya Stewart MD FAAHPM
“Two Days in the Joint”: A Visit to the Joint Commission
Jul 22nd
I had the privilege to represent AAHPM at the 18th Annual Liaison Network Forum at The Joint Commission (JC) headquarters in Oakbrook Terrace, Ill. I suspect many of us, in our professional career, have some hesitancy when approaching the JC but the “newer and friendlier” JC have some progressive, visionary work for the future of healthcare. It was a two-day conference and networking opportunity for 70 invited representatives from a diverse healthcare contingent representing a variety of organizations from the American Hospital Association, to the CDC to the Undersea & Hyperbaric Medical Society, Inc. All a friendly lot and it was very nice to see the AAHPM represented.
The JC enterprise actually has three divisions: the Joint Commission is the certification and accreditation company which is most familiar to us as the auditors showing up at our institutions doorsteps, The Joint Commission Resources which addresses safety and quality, nationally and internationally ( 41 countries so far) through provisions of education, publications , consultations and evaluation services, and the Center for Transforming Healthcare, a newer 501 C3 company which serves to offer solutions through setting up collaborative performance improvement projects with healthcare organizations in order to disseminate effective, durable solutions to the world.
The keynote plenary for the conference was given by Mark Chassin MD, MPP, MPH, President of the JC. In a nutshell, he set the stage for the future vision of the JC which is to transform healthcare into a “High-Reliability Industry” much like nuclear power and commercial air travel, which have highly effective process improvement and fully functional safety cultures. So a “simple” formula:
Robust Performance Improvement (RPI) + Safety Culture = High Reliability.
RPI involves systematic, highly effective strategies and tools for solving complex problems. Sort of a dynamic, continuous “root cause analysis” over time. RPI’s work to solve both routine processes like hand washing AND rare adverse events like wrong site surgery. Jerod M. Loeb, PhD the JC Executive VP for Quality Measurement and Research, points out that organizations must understand specific causes of problems they are trying to fix and then target interventions to those causes. He goes on to say the real challenge is the solutions (“Best Practices”) developed through this process may not work for all organizations across the board. Therefore the JC is suggesting “re-tooling” (the new buzz word) already established measures. Their newly published NEJM article (see reference below) summarizes this concept well.
Developing a Safety Culture involves trust, reportable, and appropriate use of RPI’s. The JC pointed out it’s not about developing a “blame-free “message but developing a culture that can separate small errors (blameless) from egregious(blameworthy)ones. The “Swiss Cheese Model”of assessing errors in healthcare that lead to harm was discussed extensively with emphasis on institutions assessing errors systematically, and establishing one code of behavior for all.
With all the “Big Picture” discussion at the conference as noted above, where did Hospice and Palliative Medicine fit in?
1) All issues mentioned above are important to HPM including RPI and Safety.
2) The attendees networking opportunity reinforced the support we have from a multitude of groups including the AHA, Critical Care Nurses, Critical Care Medicine, Pediatrics, the ANA, Physician Executives, Healthcare Executives, Nurse Practioners, Professional Chaplains, Women’s Health, the VA, Oncology Nursing, National Association of healthcare Quality.
3) The JC supports hospice care essentially by reinforcing the Hospice Medicare Benefit Conditions of Participation. They had no comment on the potential COP’s for face-to-face physician/NP visit mandates.
4) The JC supports palliative services and noted they were involved in standards development in the past but stated after this summer’s board meeting, they are still reluctant to develop a certification/accreditation process because they do not see any “ownership in the service” referring to funding support like CMS, Private Insurer, etc. They noted needing more “proof of sustainability” in order to move forward with certification. They agreed to listen to any input on this issue.
5) “Hand-off” communication in hospitals as patients move through different services was a hot topic and one HPM can make impact through a continuum of care model.
6) Unlike hospitals, long term care currently has no universal, comprehensive pain assessment standards.
7) The JC is reluctant to establish standards for chaplaincy services in hospitals due to fear of “creating a demand that can’t be filled by workforce”.
Maternal Mortality is increasing in the US and got a lot of attention especially related to future development of prenatal care standards. This also coincided with NICU and prenatal discussions.
9) The JC is just now starting to write standards for Children’s Hospitals. Input desired
10) The JC plans on writing standards for Long Term Acute Care Hospitals (LTACH) in 2011 which are an important population of patients for HPM.
11) The JC was embracing CMS COP’s for Telemedicine but CMS has momentarily stopped any work in this area and the JC does not know what will happen but reinforced their position that it is important for the future.
12) Health Information Technology is a complex integration program for the next few years. On example given is SNOMED-CT has no eMeasure code for “hospice care” in the comfort care section.
Overall, the meeting was very productive and interactive. The JC continues to emphasize their desire to collaborate with other organizations. With a growing number of competitive enterprises like the JC, we should expect more outreach, dialogue, and ability to contribute to their activities.
References:
Chassin MR, Loeb JM, Schmaltz SP, Wachter RM, “Accountability Measures- Using Measurement to Provide Quality Improvement”, NEJM, June 29, 2010.
Students Eager to Learn About HPM – Let’s Help Them?
Jul 9th
AAHPM was one of 50 medical specialty organizations that exhibited at the recent American Medical Association Medical Specialty Showcase in Chicago. It was a great opportunity to talk about hospice and palliative medicine to the hundreds of medical students in attendance and also reassuring for us to see how many students were interested in the field and eager to learn how palliative doctors care for their patients. The Academy’s AMA Delegate Dr. Chad Kollas stopped by the booth to talk with the students and share his experiences and the path he took to palliative medicine. In fact, many of the students were familiar with hospice and had volunteered at their local hospice after one of their family members received hospice care. We encouraged them to continue to learn about the specialty by becoming student members of AAHPM.
Submitted by:
Laura Davis
Director, Marketing and Membership
AAHPM
When Patients Are Overtreated
Jul 1st
Have you seen patients who are overtreated? If so, you are not alone.
A list of medical care services that are overused was compiled by the National Priorities Partnership, which is convened by the National Quality Forum. Non-palliative services at the end of life is included in the list. In addition, specific tests and surgeries are noted such as x-rays, cardiac CT scans, heart bypass surgery, back surgery, knee and hip replacement, prostatectomy, angioplasty and hysterectomy. To learn more, go to http://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=598
What exactly is overuse? The Institute of Medicine defines overuse as when the potential for harm of a health care service exceeds the possible benefit.
Palliative care clinicians have been quiet observers of overuse. Dr. David Weissman, professor emeritus at the Medical College of Wisconsin, says, “The continued use of chemotherapy by my peers, as the end-of-life approached, was one of the reasons that drew me to the new field of palliative medicine in the late 1980s.”
Patients are speaking up. This month, Consumer Union’s Safe Patient Project launched a “Share Your Story” survey of patient experience of overtreatment across the lifespan. Go to www.treatmenttrap.org and click on “Share Your Story”. What do you think about patients sharing their stories of overtreatment?
Palliative care enables patients to receive the care they need, no more and no less. That’s why the National Priorities Partnership included palliative care and end-of-life care as one of its six national priorities.
As a health care professional, if you have seen patients overtreated, what do you do? How do you ensure patients receive only the care that will benefit them?
The writer is the author of The Treatment Trap (March 2010) and was chief architect of the Robert Wood Johnson Foundation’s palliative care strategy.
Inside the Process of Authoring a Book: Diane Meier on Palliative Care: Transforming the Care of Serious Illness
Jun 24th
Our recent book, Palliative Care: Transforming the Care of Serious Illness (Jossey-Bass, San Francisco 2010), has been a long time coming. I got the invitation from my co-editors Stephen Isaacs and Bob Hughes of the Robert Wood Johnson Foundation over three years ago. The book was to be another in an annual series of books on health reform in areas of significant investment by the Foundation. Prior volumes addressed the Campaign for Tobacco Free Kids and School-Based Clinics, among others. I was asked to both write an introductory essay placing the field in context, and to help select a series of previously published articles for reprinting in the volume. The audience for the book was a matter of some discussion- we settled on the educated public and, we hoped, health care policy makers. The reprints were to serve as the signal and seminal pieces that exemplified the evolution of the field from its inception to its current status.
Sounded simple enough.
Many, many, hours and three years later, we had a draft ready to go press. The articles were chosen with a great deal of input from colleagues in the U.S. and around the world and lots of great pieces of writing had to be left out for lack of space. My essay started with the roadside hospices for the Crusaders of medieval times and ended before the passage of the 2010 Accountable Care Act and I learned way more than I anticipated about the threads that contributed to our field now- the 14th century origins in church-sponsored hospitals for the poor and hopelessly ill; the evolution of the place of death from a familiar experience to a mistake in the “medical model” of the modern world; the new science of pain and pain management in the 1970’s; the revolutionary and determined roles of three middle aged women (British nurse, social worker and physician Cicely Saunders, Dean of Yale University School of Nursing, and University of Chicago physician Elisabeth Kubler Ross) in a male dominated medical business culture; and the power of a federal payment mechanism (the Medicare Hospice Benefit) as a mediator of social change. The development of the field of palliative care as an approach to the human experience of illness and disability stands on the shoulders of at least a thousand years of social evolution. Humbling. It helps to understand what came before in order to think about what should happen next. Some people want to use the book in colleges and universities and Schools of Public Health. Hope for the future.
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