Annual Assembly

A Developing Countries Scholar’s Perspective on the 2011 Assembly

Attending the 2011 AAHPM &HPNA Annual Assembly in Vancouver February 16-19, 2011 was a wonderful experience for me. It would have been impossible without the support from AAHPM for physicians like me who are working in developing countries. I got the opportunity learn new clinical and scientific knowledge of palliative care by attending different sessions on different days including the preconference workshops. It was a good platform to know and to develop personal relationships with palliative care workers from Canada, USA and other parts of the world. I am already benefitting from this new relationship to improve palliative care in Nepal.

I am going to conduct a one-day Palliative Care Workshop for fellows of different departments March 25, 2011. I got the chance to meet Steven M. Radwany during Annual Assembly who is helping to conduct the palliative care workshop by supplying 60 copies of the Primer of Palliative Care 5th Edition with the help of different friends from AAHPM. I met Fraser Black & Robin Love from INCTR who are also helping me. I have already received “INCTR Palliative Care Handbook” from INCTR Head Office, Brussels, Belgium for the participants of this workshop. Frank Ferris from San Diego has shown different opportunities to improve my personal career and to develop palliative care in Nepal. The educational flash drive provided by Laura Davis is very useful to conduct my daily palliative care activities.

Besides I could see the beauty and development of Vancouver and feel the warm hospitality of the Canadian people.

Bishnudutta Paudel, MD

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!

Peds SIG Offers New Avenues for Involvement in the Field

Although it was painful to get up so early on the final day of the AAHPM Assembly in Vancouver, it was completely worthwhile to attend the meeting of the Pediatrics Special Interest Group (SIG). Over the years that I’ve attended this meeting, it’s been amazing to watch the evolution of interest and attendance in our SIG, and the parallel explosion of pediatric education, research and advocacy opportunities.

In 2007, our statewide pediatric palliative care (PPC) network OPPEN (Ohio Pediatric Palliative and End-of-life care Network) organized a national conference as a follow-up to the National Hospice and Palliative Care Organization’s (NHPCO) pediatric conference in Dearborn, Michigan in 2004. These efforts were organized precisely because there was no place for PPC providers to go to find educational and research information and to network with colleagues; most national conferences had only occasional, if any, pediatric content. Fortunately, that has certainly changed!

For the past few years, the AAHPM has offered greatly increased pediatric content at the Assembly, with pediatric sessions in almost every concurrent slot, as well as large numbers of pediatric paper presentations (which are often award winners). Pediatric representation exists throughout the organization, from workgroups and committees through the Board of Directors.

Similarly, NHPCO has been offering a pediatric track at its Clinical Team Conference for several years now, and its advisory group ChiPPS (Children’s Project on Palliative and Hospice Services) has expanded, undergone strategic planning, and taken on a leadership role in equipping hospice and palliative care organizations to care for children and in working closely with NHPCO in its advocacy and policy activities (www.nhpco.org/pediatrics).

The American Academy of Pediatrics (AAP) has also jumped on the PPC bandwagon, with the establishment of the Section on Hospice and Palliative Medicine. This group is focusing primarily on policy and educational activities, including opportunities for scholarly activity through the AAP’s main meeting, the National Conference Exhibition. The Section maintains 2 listservs that boast healthy discussion about many aspects of our field, 1 for members and 1 for any interested parties; Affiliate Membership is possible for non-physicians as well (www.aap.org; check out the web page soon for a more expanded discussion of each of these national opportunities for PPC involvement and commitment).

The Center to Advance Palliative Care has recently increased its pediatric focus too. Last fall, the annual conference included a pediatric track for the first time, and that will continue this year. Palliative Care Leadership Center tools and training for programs interested in starting or growing a PPC or hospice program have been available through a number of different sites for years; in 2008, 2 pediatric-specific sites were added (Akron Children’s Hospital and Children’s Hospitals and Clinics of Minneapolis) and a new pediatric curriculum was developed (www.capc.org).

And there are other groups involved with PPC as well. A few more highlights include:

  • PEPPERCORN, the Pediatric Palliative Care Research Network, a dedicated group of researchers from a number of sites across North America who are working individually and collaboratively to advance the science of PPC
  • The Hospice and Palliative Nurses Association (www.hpna.org), which has successfully developed a pediatric nursing certification examination in hospice and palliative care, and is also developing accompanying educational material
  • The National Networks for Pediatric Palliative Care (www.network4pedspallcare.org), a grassroots effort focused on developing a web-based clearinghouse of programs and information for families and providers.
  • The Pediatric Hospice and Palliative Medicine Competencies Project, a group of PPC leaders who have been working with the original HPM competencies document and authors to create a companion resource for pediatrics; importantly, the AAHPM’s Board of Directors approved support for this project at this year’s board meeting.

During this time, the Academy’s SIG has continued to meet and grow. In the last few years, we’ve become more organized, along with all SIGs in the Academy which are receiving more support through the new and expanded Communities model. We’ve developed an elections process, allowing a rotation of leadership and the opportunity for younger or newer folks in the field to become involved. This year’s Assembly featured a Pediatric SIG-sponsored session which was very well received. And there were a tremendous number of great suggestions for next year’s Assembly that were generated at the SIG meeting. Our next big push will be for a pediatric plenary!

In short, it’s a great time to be in pediatric hospice and palliative care. Seeing colleagues, learning about many new avenues to become involved in the field, talking about challenging and uplifting situations, sharing wisdom and lessons learned, and literally catching the contagious excitement among us were just a few of the reasons to get out of bed on Saturday morning for the SIG meeting. Hope to see you there next year in Denver!

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.

Dancing with Broken Bones (Feb. 16th)

“Where there is love of humanity, there is love of the art.”

This quote from Dr. Moller’s talk really resonated with me as a relatively recent graduate of medical school.

In a thought-provoking exploration of impoverished patients struggles in the healthcare system at the end of life, an underlying theme was the importance of exposing training physicians to life as a poor and terminally ill patient. Nowadays, every medical school has managed to carve into an ever expanding curriculum a course on the “human side” of being a doctor; how to assemble body parts and physiologic processes into caring for a real live human being. Despite many strong programs, I suspect the vast majority of medical students leave school without the tools needed to truly care for the patients they will encounter in residency.

Exposing medical students and residents to palliative care in all settings and across all socioeconomic lines will only help to strengthen patient care.

Gratitude: Service of Rememberance and Celebration

What a wonderful way to celebrate and remember all of us who care for our patients. The theme brought us back to Mother Earth as we are in the beautiful setting of Vancouver where we all are here to support each other. The symbol of the tree was used in several ways from the tree created during the conference by those attending and remembering those dear to them and also on the front of the handout with the Arbutus Tree (Madrone) which holds the tile of most sacred to inhabitants of this coastal region. I think the tree even though it looks like they stand alone are actually connected in many ways. And so are we.

I especially enjoyed the celebration because of it’s emphasis on gratitude. I think in the hard days we face and the many challenges, many of them discussed during the conference, that we remember to return to ourselves and be grateful. To have gratitude as we complete our day for the work we are called to do. Grateful for the sun that warms us, the ground we walk on and the air we breath. To also cherish our heritage personally and united as presented by Gabe George and Carleen Thomas from the Tsleil-Waututh Nation meaning “People of the Inlet”.

Gabe shared with us the loss of his brother from HIV and how he learned that healing is best done through song. Carleen and Gabe shared many songs with us and the healing in the room could be felt.

Patrick Clary also shared with us his healing journey which has taken many years and started in his youth with his magpie.

In a unique experience, often we share our monetary offerings, but what we received was a gift made by Kelly Two Wolves (she was introduced to us in the earlier plenary session). The beads represented the North (Red), West (Black), South (White) and East (Yellow) and the representation of the colors of the human race. The beads were presented in a bracelet, circular, joined and never ending showing we are ALL connected (related). This reminded me of another practice I learned this year, The Medicine Wheel.

In closing we joined in the Aztec Prayer of Community.

Only for so short a while, O God,

You have loaned us to each other.

Because we take form

In your act of drawing us.

And we take life

In your painting us.

And we breathe

In your singing us.

But only for so short a while

Have you loaned us to each other.

Thank you for this wonderful experience.

Palliative Care in the Age of Healthcare Reform: The Impact on Your Practice (403)

Diane Meier’s talk this morning was less a presentation than a call for action to the palliative care field. Dr. Meier spent a year working on capital hill and has continued to advocate for palliative care on a local and national level.

She began with a review of the Affordable Care Act and the challenges faced in our country given the current unsustainable spending on healthcare. More and more people are looking to the value equation: Value=Quality/Cost. The United States struggles to increase value and has been unable to accurately measure and increase quality, costs have continued to rise. As we debate how to cut costs it is critical that palliative care not be left out of the discussion.

Currently, most of the talk around bending the cost curve has been related to changing payment structures including the formation of Accountable Care Organizations (ACOs). High quality, well integrated palliative care is a critical piece the health care continuum, and we should be advocating that it is included in any discussion of ACOs.

Unfortunately, there are very few voices from the palliative care community “at the table” in Washington and so our concerns are often not addressed. Only a tiny portion of NIH funding (0.01%) is devoted to research in the field of palliative care which only leads to further misunderstanding of our views and mission.

So how can we make a difference? How can we make sure the palliative care is included in health care reform efforts going forward? Dr. Meier outlined several steps that we can take as a profession and as individuals.

  • Language is important. We must be consistent in how we talk about what we do. Her suggestion: “Palliative care is about matching treatment to patient goals.” What do you think?
  • Submit your organizations data to CAPC’s registry so that quality is measured and improved.
  • email/call/write a letter to your congressperson. AAHPM has made it easy!
  • Mark time off in your calendar to meet with your congressional representatives to discuss and lobby for palliative care.

Our elected officials want to hear from us and they take our views very seriously. As an movement we need to start speaking up or health care reform is going to pass us by.

Building Bridges, Breaking Barriers…February 16 preconference

Although I was faculty rather than participant, this workshop about horizontal and vertical violence (“Bullying”) was a learning experience for me. As the only physician on the panel I expected to be isolated, to feel like a concentration-camp guard at the Holocaust Museum; instead I was surprised at the number of physicians in the room, often, it seemed, with experience on both sides of the bullying divide.

While the literature suggests that nurse-on-nurse bullying is slightly more common in health care, that has not been my experience. Trained in an environment in which bullying was a norm, physicians have a tough time escaping from that practice. It was clear that this group of physicians was determined to heal, and that the others on the palliative care team were equally determined to travel on the same journey. Most of us experience bullying in our work, and the nursing studies which dominate the literature suggest this is a significant factor in leaving the profession.

Modern teaching theory suggests that adult learners do well with short doses of didactic material and much better with “showing” rather than “telling.” In the interest of “showing” we inserted an episode of “horizontal violence” into the didactic session as an unannounced role play, with one presenter harrassing another to the extent that the room became visibly tense and uncomfortable, while the undermined presenter grew more flustered, shaky, dropping her materials. We stopped almost immediately to debrief. One of the participants asked “what could we have done to stop this,” and we spent much of the rest of the meeting examining this question in parallel experiences of “real life.”

Reflective practices which teach us to move toward appropriate action in spite of our ever-present fears are the foundation of resistance to bullying. Gifted teacher Don Marks hleped us understand the effect of these practices, actually decreasing the activity and size of the amigdyla, the brain’s “fear center,” increasing the size of the insula, the compassion center.

Again, understanding that “showing” works better than “telling,” we demonstrated two practices, reflective writing and a meditation. Participants were enthusiastic, understanding how these practices could well move them to a place where they could better intervene in bullying episodes on behalf of themselves or others.

Patrick Clary, MD

New Hampshire Palliative Care Services

PalliMed reception

The PalliMed/ GeriPal co-sponsored reception last night was a success. As repeatedly and succinctly put by social networking guru Christian Sinclair, the purpose of this event was to meet those with whom we’ve been communicating for the past 12 months, whether by Twitter, List-serve, blog or Facebook. Plus it’s fun! Present were PalliMed contributors and its principals Drew Rosielle and Christian Sinclair. GeriPal’s Alex Smith mingled with the crowd of more than 50 (I arrived late so may have been more earlier) with drinks and hors d’oeuvres that were gone by 9:30 pm. Others from the Social Media presentation were in attendance.

Putting real (vs virtual) faces with names is a luxury in this era of social media, where opinions are rife but the exchange usually one-sided (instead of truly listening one is busy crafting a response) so hope we can use these associations to further our personal and professional life skills.

Thanks for the break.

Feeling Our Fire

Earthy, dynamic, funny, rich in the wisdom of connection, reflection, and rejuvination…This describes this morning’s plenary by Dr. Sherry Showalter. Her words and movements celebrated this work we do. She reminded us that that which is to provide light, must endure burning, and that we who strive to heal, must, each day, heal ourselves.

Her message invigorated us with renewed purpose, inspiring us to go forward with fresh eyes and weightless spirit, to bear witness and share strength, to open the door with an open heart and open mind, to achieve comfort, to offer hope, to create healing.

Wado Dr. Sherry “Charles” Showalter. Wado!

Karen Whitley Bell, RN, CHPN