Paul Tatum III, MD

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Posts by Paul Tatum III, MD

AAHPM Calls on Washington (and you should be in touch with your local folk!)

Thoughts on Local Sausage-making and DC:

I spent an evening walking from the Washington Monument to the U.S. Capitol Building last week. Although the classic reference about legislation is “sausage-making” and something you don’t want to watch, I found the area by the capital buildings an especially peaceful spot to stop and admire the view of the reflecting pools projecting the mirrored image of our illuminated Capitol after a busy couple of days in DC. Despite all of the negative coverage about modern politics, the fact is that those working in DC are amazing, intelligent people. I couldn’t help but to be inspired by the promise that is the United States.

The AAHPM Public Policy committee held its second DC fly- in last week which proved a great chance to see DC in action. I was especially impressed by AAHPM’s policy team and its lobbying colleagues who are working hard to help represent all of us in Hospice and Palliative Care.

Perhaps you are thinking, the budget is a mess, health care reform is too controversial, and nothing can come of a DC visit?

To be honest, so did I. But I was wrong. The connections made this trip matter.

Sausage making in the Sinclair Lewis era was a disgusting mess and high risk, and I suppose that is why it was an apt metaphor for policy-making. Well, today I know my sausage makers, Patchwork Farms. They farm near me and I get their wares at my grocery. I know them and trust that what they produce is Missouri locally-raised pork that is high quality and raised in such a manner that is safe for my community.

And this is what is needed of you. You need to know your legislative representative and senators. (You can find them and e-mail them directly via AAHPM’s Legislative Action Center.)

Ask to meet them in your home town. Meet their health care aides.

And what do you say?

  1. Tell them who you are
  2. Explain what Palliative Medicine is. (I told the story of a rural gentleman that didn’t quality for hospice, but needed a good symptom control plan to help him achieve his key goal of avoiding hospitalization, and as a result he was able to go fishing and be at home when death came)
  3. Offer to be a resource for them locally
  4. Ask for support for the Palliative Care and Hospice Education and Training Act (read more about PCHETA here)
  5. Let them know of the bills that AAHPM supports (see link to AAHPM policy committee here)
  6. Make plans to stay in contact

Shouldn’t you know who is writing the laws that will determine the future of Hospice and Palliative Medicine and let your relationship help guide those future laws?

But do stay on target. Make sure you review the AAHPM policy site before your meeting, and if you get a question that you can’t answer just say so and promise to get back to them with an answer.

State of the Science Part II

Wow! A day and a half to get home. Who knew there would be snow in Minnesota in the winter? I hope you find yourself as reinvigorated by the Assembly as I have been.

So what were the other key articles? Well, perhaps you’ve seen Lyle Fettig’s excellent post at PalliMed complete with hyperlinks. If not, here’s Part II:

What is the experience that children undergo when treated with Stem cell transplant (SCT) for malignancy? Parents and Physician’s perspectives are presented in Ullrich CK, Dussel V, Hilden JM, Sheaffer JW, Lehmann L, Wolfe J Blood 2010 115: 3879-85. While success rates are improving, 5-year survival for children undergoing SCT is 50-60%. Physicians and parents of children who underwent SCT as the last mode of cancer-directed therapy reported knowing that the treatment will not result in cure less often and later than those of children who do not undergo SCT. This was associated with more use of life-sustaining treatments, less planning, and increased symptom burden for the children.

And for those with Dementia, the impact of pneumonia is described in Givens JL, Jones RN, Shaffer ML, Kiely DK, Mitchell SL Archives of Internal Medicine 2010 170: 1102-7. This study can be used to help surrogates decide whether or not to initiate antibiotics in severely demented patients in LTC. Residents in 22 Boston area nursing homes were studied.

—Treatment with antimicrobial agents is associated with longer survival (273 mean increase in days)
—No differences were noted between survival based on route of antimicrobial delivery
—Patients who lived and received antimicrobial agents had more discomfort
—For patients who died, there was no difference in comfort for those who did or did not receive antimicrobial agents or in other words, withholding antibiotics did not appear to increase suffering.
Finally, our State of the Science closes with two articles about surrogacy and advanced care planning.
The first study presents a randomized trial of disease specific discussions from the Respecting Choices program of LaCrosse Wi. Patients and their surrogates were randomized to either a facilitated interview or usual care. For patients with CHF or ESRD, a facilitated, structured patient-surrogate interview improved surrogate understanding of patient preferences for care at the end of life.

The final study used a randomized trial of video to facilitate end-of-life conversations with cancer patients. El-Jawahri A, Podgurski LM, Eichler AF, Plotkin SR, Temel JS, Mitchell SL, Chang Y, Barry MJ, Volandes AE J Clin Oncol 2010 28:305-10 Viewing a video depicting end-of-life care options increased patients’ preference for comfort care, and decreased their desire to receive CPR and other life-prolonging therapies.
So in conclusion, it’s been a great year for Hospice and Palliative Medicine. To all of you HPM researchers, keep up the great research!
And Finally, Happy Anniversary to HPNA on reaching such a great milestone!

The State of The Science 2011

The last day of the Annual Assembly is bittersweet as things come to a close, but it also means it is time for one of the highlights of the meeting year after year,the State of the Science. If you missed it, make a point to see the next one! Drs. Nathan Goldstein and Wendy Anderson reviewed articles from 2010 with a systematic format and highlight the key articles from the year. They critique the methodologies and analyze the results to help decide how the articles should be applied to every day practice.

This last year has been an amazing year. The number of high quality studies is higher each year, and they are showing up not only in high quality journals, but also in the media where they may impact the public. The research is demonstrating the value of the work we do and directing the care of the future.

Not surprisingly, things began with Temel’s trial of early palliative care for non-small cell lung cancer NSCLC (N Engl J Med 2010 363:733-42) The clinical bottom-line is that early palliative care integrated with standard oncologic care for patients with metastatic NSCLC is associated with improved QOL, mood, less use of aggressive therapies at the end-of-life, and longer survival, but they caution that we don’t know precisely why, and that this study was done in a mature program and limited to NSCLC.

Next, they reviewed Dr. Amy Abernathy’s RCT of oxygen vs. compressed air in patients with a prognosis >1 mo who have normal oxygen saturations (Lancet 2010 376: 784-93) As compared to compressed room air, oxygen therapy delivered by nasal cannula provides no additional symptomatic benefit for relief of refractory dyspnoea in patients with life limiting illness. Questions remain though about whether room air will be acceptable to patients and family, and whether a fan is a preferable alternative.

Dr. Unroe’s analysis of 1 year outcomes after prolonged ventilation at Duke may be useful to help patients and families with decision-making. Ann Intern Med 2010 153:167-75 Patients who received prolonged mechanical ventilation had high rates of mortality and functional dependence at hospital discharge. Between hospital discharge, 3-months, and 1-year, improvement in functional status was rare, high mortality persisted, and quality of life was poor.

The factors that influence surrogates understandings of prognosis was analyzed by Dr. EA Boyde in Crit Care Med 2010 38:1270-5 and can help us with a conceptual model of communication. Surrogates integrate information from a number or sources when estimating a patient’s prognosis, including providers, their knowledge and observations of the patient, intuition, and faith, and support of loved ones.

Curious what other articles were reviewed????

Stay tuned for Part II after the plane lands.

Why you should be involved in policy – More from Diane Meier

Diane Meier made a compelling case for the PC provider to be involved in the policy process.
“The original sin”- of health care is that providers and patients determine what care is necessary with no regard to cost vs. benefit.

We spend 16.2% of GDP on healthcare, but rank 40th in quality indices worldwide. And that said, we spend 7.2% of resources on Paperwork/Admin, while the rest of the world is 3.2% We spend more on tests, hospitalization, etc.

So
WHY IS PC IMPORTANT TO HEALTH CARE REFORM (HCR) and Why is HCR impt to us?
Our patients (Chronically ill) account for majority of $ spent (but they have poor care and don’t get what they want (see teno Jama 2004:291:89-93) Medicare’s sickest 10% spend 37% of resoursces. Sickest 10%=$44,200 /yr vs 7,000/yr on rest. But the pts who get highest intensity of care report the lowest quality of care. (teno Jags 2005:53 1905-11.)

Does PC improve quality? Yes.
Per Casarett in Jags . If the patients with cancer recall Occurrence of Prognosis /goals of care they have better quality care, better grief process, lower cost.

If Rural patients with advanced cancer in NH and Vt received Telephone PC support from nurses, there was improved quality of life, symptom and less utilization. Survival interesting was longer but too small to be significant Bakitas M Jama 209 302 (7)341-9.

SO PC leads to better resource use, reduced bottlenecks in high cost units, and improved throughput (key to Hospital Directors) . We are the solution to this.

Here is one Conceptual model: Dedicated team=Focus + time= Decision making/clarity/follow through.
But this is Hard for administration. They think it’s happening. We need to make the case that it is not, and we can do this.
Email from CEO- “you mean no one is in control” YOU GOT IT.

And what is the Impact of PC Health affairs 2009

2% is the annual death rate in hospital
PC at minimum should do that. But ideal upstream and dc.

At 6% we can save a 300 bed hospital 3.15 million dollars

Here is the key:
Why HCR critical for PC
1. No GME dollars for fellowship
Cards /geri/ fellowship paid for by medicare
Pc fellowship paid by philanthropy ##1 threat to field
2. No loan forgiveness
Students with $140 K debt
3. No career dev support for junior faculty in medcal/prof schools
Geriatric career award is a model of how we can move forward

4. Inadequate NIH inv in ev base0.8% is invested from NIH in PC research
5. No compensation for distinct effort/skill of pc practitioners
Ex. Critical care codes get well compensated multi-organ, distraught families (hey those are our patients too)

6. No financial incentives (and have a neg incentive) for hospitals/NH, providers to deliver PC.
Some have even said won’t refer to hospice because they lose a lot of money (back to the original sin-
7. No reg requirement for PC services

Policies we need: Access and quality
To improve access we need a workforce (MD and nurses)
Financial incentive (positive reward)

No work force= no quality
we need Facuty to teach the next generation. So we need a PC training act
We need evidence base, therefore NIH must invest.

All of this is logical and simple, but to accomplish this is 10 yr process on Hill.
And the legislators really care about the local constituent. You need to be involved.

See the next post for how.
Paul Tatum

Policy Goals

Sean Morrison, showing his Canada pride in the Hynes Convention Center halls

Sean Morrison set a fantastic vision for the ultimate goal for Palliative Care (PC) in the future:
All patients will know what PC is and when to ask for it
All providers will have the knowledge and skills to administer basic PC
There will be the necessary infrastructure to deliver HIGH QUALITY PC.

But as they say, you can’t get there from here.

Both Sean and Diane Meier in her policy talk outline a vision for policy change.
Look for the AAHPM website to have a posting of the updated policy goals soon.

We must address:
1. work force (both getting the docs for now, the docs for the future, and the faculty to train them)
2. access and quality
3. increasing the evidence base
4. correcting public misperceptions
The academy’s policy committee meeting adds access to opioid analgesics, which they word broadly to include timely access to prescription medicines.
(Look for more on the REMS later, but now I need to go get some REM sleep)

To Sean’s AM talk: Policy changes 1, 2, and 3 must be to fix the GME cap. Fellowships currently depend on philanthropy as Medicare dollars don’t flow to the fellows as they do in other areas. This is not sustainable long term.

Paul Tatum

Please help beat the Death Panel label

See prior post on Diane Meier and importance of language.

So if you use the term supportive care you get more consults for your pall care program. There is a lot of misperception and bias associated with various names like pall care/hospice care/supportive care/comfort care.

Yet the name that stuck with the public is death panel.
Life panel is one alternative to rebrand the death panel label, but does it really do the trick, or does it just remind us of Death Panel?

What clever title do you prefer to trump death panel??????

Paul Tatum

Diane Meier and language and policy-making

Language Matters.
And misuse of language and misperception is a Major threat to us.
What was the misperception:
We are death panels and rationing

and it was in the eyes of Professionals(our colleagues, the public, AND Policy Makers
One implication of this: a grant was all but funded, had to be vetted in a Politicos office due to the source: the result, No $ because Palliative Care (PC) in the title
How big an issue is this: Diane Meier couldn’t get an interview for one committee because in the words of the staff office “Palliative Care is radioactive!”
we have a huge branding problem

What language led to this debacle: from the original “death Panel” bill
Section e. “an explanation by the practitioner of the continuum of end-of-life services and supports available.”

The result, former NY Lt Gov. Betsy McCaughey found the gotcha sound bite. “congress makes it mandatory to have counseling session that will tell them how to end life sooner, how to decline nutrition”
and ultimately Sarah Palin’s response on FACEBOOK “ my Down’s syndrome baby will have to stand in front of Obama’s “death panel”8/7/09
Language is really important.

Everything is about “OPTICS” . How does it look. We as PC were bad optics because we have not been trained about how we communicate. Papers that talk about EOL care, or terminal became “radioactive.”
The ultimate impact: adv care planning, nih funding, quality measures, hospital accreditation , gme funding for fellowship loan forgiveness all removed from HC reform bills due to slippery language.

We must communicate who we are and what we do to pt and family.

Diane emphasizes:
our Language needs to focus on the needs of audience.
What is it we fundamentally do: we match treatment to patient goals.
EOL misrepresents the purpose of pc. we match treatment to patient goals.
If we want to help pts and families who need us, we cannot force them to 1st agree they are dying.
we match treatment to patient goals.

(Hmm, she made that point 3 times in Bold, I guess it’s important!)

Paul Tatum

Diane Meier is working for you on Policy.

I thought I knew that the one certainty in life was Death and Taxes, but with the debates over health care reform and “Death Panels” I’m not even sure death is a certainty anymore, or at least that is the perception provided by the media sometimes.

That said, isn’t it good to know Diane Meier is working hard for Palliative Care in the Senate this year in a Health and Aging policy fellowship. To be clear, her remarks do not represent the views of the Senate or Senator Harkin.
The good news she emphasizes is that the rapid growth in palliative care programs and hospices gives us a place at the table for negotiations. WE ARE A NECESSITY in the health care reform solution. We need to change our outlook from fighting for the scraps, to a mentality that we are the key to solving health care problems in the US and we have growing numbers and impact.

Look for a few posts today and tomorrow to summarize–
1. We need to learn the right language to make our case meaningful and to make it stick with the audience. Look at what the wrong language can do. Think Death Panel
2. Look for a summary post of Top policy needs and why

3. Why you should be involved in policy
4. How to get involved in policy
Paul Tatum