Archive for March, 2010

Managing Neuropathic Pain in Palliative Care

What an enjoyable and totally painless experience attending this lecture turned out to be. Stefan Freidrichsdorf was entertaining as well as completely knowledgeable about this subject. His use of movie clips to illustrate a point was unique; his case study was compelling. The case study had multiple elements that lent themselves to illustrated several points throughout the presentation. Stefan started the lecture reminding us that we begin with acute pain management: by the clock, by the child, using the appropriate drug, using the WHO ladder. From there, he launched into a description and discussion of neuropathic pain and the different modalities used to treat it. Starting with opioids, going to antidepressants, using anticonvulsants, and then using other integrative therapies. neuropathic pain is not a mountain to be avoided, but rather a challenge that can be successfully met. He showed us, through his case study, how he used various modalities, to obtain successful management of severe neuropathic pain with a challenging pediatric patient. Included was an excellent overview of Neurontin and Lyrica, with the various side effects seen in children.

I am not a pediatric clinician. I’m at this Conference trying to learn as much as I can, because my organization is actively recruiting more pediatric patients to my facility. I need to be better capable of caring for them. Dr Friedrichsdorf inspired me to continue my studies with this population. Like the geriatric population that I have cared for for so long, this population lacks RCTs specific to their needs. Much has to be extrapolated from adult studies, with much trial and error.

I’m anxious to hear more from researchers and clinicians like this speaker.

Beverly Douglas ARNP

LifePath Hospice

Tampa, Florida

Compassionate and Mindful End-of-life Care: A Relational-Contemplative Approach for Clinicians

Roshi Joan Halifax is no longer afraid of getting what the dying have because she has recognized she’s already got it. We are all mortal. Both as a Zen priest and medical anthropologist she has paid 40 years of close attention to the marginalized position of the dying. At Upaya Zen Center in Santa Fe she long-ago established a training program, “Being with Dying,” that approaches the problems of suffering at the end of life by proposing an end to the duality that divides us from the dying. Compassion means “feeling with,” and today she gave us a very fast overview of the sources of our suffering not only as patients but as caregivers and clinicians, asking us “how can we create the conditions that will allow dying people to express themselves most fully?” We have wonderful therapies for physical pain but the “total pain” of losing the world is more difficult.

This can’t be made easy, but we can accompany our patients and loved ones more compassionately by recognizing our own struggles with burnout, compassion fatigue, moral distress, colleagial hostility, and the structural violence of our “system of no system.” Roshi Halifax proposed mindfulness practices as providing another way of relating more compassionately. Contemplative practices can teach us to focus our stable attention in a way that allows our open presence to patients in need.

Mindfulness practices have been established in RCTs as an effective stress reduction strategy. Roshi Joan’s critical insight seems to me to be the need to take better care of our patients by taking better care of ourselves as clinicians and caregivers.

I was left longing for the hour long dharma talks and half-day seminars that have been my previous contacts with her ideas. For more detail regarding the integration of contemplative practice and clinical work, please review the article Dr. Halifax coauthored with Tony Back and others in JPM volume 12 number 12 2009 pp 1113-1117, “Compassionate Silence in the Patient-Clinician Encounter: a Contemplative Approach.” Or better yet, enroll in “Being with Dying.” The 2010 spring session is full. I just signed up for 2011.

Patrick Clary, MD

Hospice Medical Director Course: A seamless Presentation of Material

Julie Bruno, AAHPM Director of Education, started the morning plenary session with a reminder that “life happens” at preconference workshops just as it does in real life, so one of the session speakers had to attend to a family health matter. The schedule was therefore rearranged a bit to provide the two remaining faculty time to cover the additional lectures. The speakers are experts and the presentation seamless.

So first off, Pat Schmidt gave her lecture on Communication, Psychosocial & Spiritual Care. Everybody has a story to tell, and sometimes they need help, but we have to hear and understand it for us to achieve our goal of allowing them to die with dignity and in comfort. She listed the barriers to effective communication to help us avoid them, and what we can do to make it better: body language, time, place, attitude. Different settings (hospitals, SNFs, ALFs, and homes) have different cultures and ground rules to consider. So do different patients. So do the different physicians who see each patient: the old yin-yang symbol about how we interact as consultants is pertinent here. Communication is not just about words; we listen not only to what is said, but how, and why – because we want to recognize and validate emotions, and words are just not good enough.

The other IDT members can be invaluable here, because they have more training in psychological, social, and experiential topics than physicians; Cecily Saunders was first a social worker. The entire team is essential in helping the patient and the family deal with the grief of illness, and death, and bereavement. Our tendency as healers is to want to fix, to do something, but what we really need to do is just be present, listen, accept, validate, and try to understand. It’s harder to take a spiritual history than a sexual history. Grieving is helped y our presence, faith, noticing what’s needed, offering, doing, patience, acceptance, and empathy – little of which we learned in medical school. The team chaplain can be of immense help when there is spiritual pain – which may be relieved, but sometimes worsened, by religion. Spiritual palliation is the goal; this requires reflective listening. Communication is the foundation of our work, and all members of the IDT play a role in the management of complex symptoms.

Next up was Lyra Sihra (yes, she told us, it rhymes) who talked about Medical, Ethical and Legal Issues. Ethical practice follows with the four principles of autonomy, beneficence, nonmaleficence, and justice (societal and distributive) – all discussed, as was the principle of double effect, now being used more by courts and less by physicians, and withdrawing treatment – on which the ethics and policy have changed; n.b.: in medical ethics today there is no moral distinction between withholding treatment and withdrawing it. Long discussion of Karen Quinlan, Nancy Cruzan, Terri Schiavo, and the need for advance directives ensued.

Palliative sedation, and the new concept of “respite” palliative sedation, and whether they are OK for existential distress, and the fine lines between this and euthanasia and physician-assisted suicide concluded that at lease in the US, the Supreme Court has ruled that this is a state, not a federal issue. So know your state’s law; it’s important to understand what your courts say about what you do.

Click here to read more: James Condon Blog.

Exhibit Hall Action

Smiling Guests at the Exhibit Hall

This is a belated entry – I couldn’t get in to post last night, but still wanted everyone to know about the great action in the AAHPM exhibit hall!

It’s 9:20 and I’m just returning to my hotel room after a long and exciting day at the AAHPM Annual Assembly. I missed the pre-conferences but the word is that they were fabulous! The down side of being a board member is having to miss the pre-cons – and there’s SO MUCH that I need to learn – especially as I’m preparing for my Board exams in the fall. I grabbed a brochure for the August board review course in Chicago.

At 5:30, the exhibit hall opened – WOW! It’s bigger and better than ever. I had the privilege of giving the poster prize to Dr. Jillian Gustin from Ohio State University. Go Buckeyes! Stop by and check out her research on symptoms of depression in terminally ill parents with young children.

Find some time to visit!

Gail Austin Cooney MD, Hospice of Palm Beach County, West Palm Beach, FL

Contemplative Interventions

In looking at the gifts we have been given that we have not opened yet in our everyday activities and practices, it is good to still ponder with awareness that there is something else possible. In doing so I had not thought about bringing in the meditative practice not only for myself but for my patients. In the meditative process the practice of honoring the comfort from the silence can be very powerful.
In this session I became aware of the “May I” phrase. May I extend comfort and empathy to you? May I share with you love. By asking may I, it feels like an invitation to join in instead of talking at the person.
I was also moved by a new tool in the boxes we carry in ourselves that I was introduced to during this session. The simplicity of the pulse. I ask you the question, have you ever taken the pulse of someone not for its clinical value but to connect in a mindful way?
Have you ever taken your pulse? What is it telling you right now? Can you see anyway this could help in your daily practice as a meditative way to help mindfully recenter yourself?
I can see in the middle of a busy day the benefit to sit for a few minutes in a meditative way taking my pulse and being mindful of where I am and what I am feeling. This may be enough of a break in a busy day to reduce the stress of what I do and reduce the burnout that comes from some of the stressful but beautiful work we do.
Barbara Rogers, MSN

Triaged to “comfort care only” in a pandemic means…?

How would you triage patients to get life-saving care or not in a lethal epidemic?

What kind of care would your hospice patients continue to get?

What is the role of the HPM specialist in a mass casualty event?

Come to Room 309 at 12:15 today for Pandemic Palliative Care: Time to Plan.

See you there!

Coding and Billing… I finally see the LIGHT!

Billing and Coding is complex and certainly NOT a core medical competency for most doctors. The Precourse discussion by Martha Twaddle, Janet Bull and Christopher Acevedo was both timely and enlightening.

Here are some of the salient points from the talk:

  • Look at complexity BEFORE coding Time!!
  • If the clinician bills only on time you are losing money AND likely billing inappropriately!
  • Use Extender codes if the visit exceeds typical time for the billed visit
  • Always document WHY you are seeing the patient EVEN when making a follow up visit
  • GIP level care cannot be used for caregiver breakdown anymore- this is an old CMS rule that was changed a few years ago; you MUST have a symptom to manage to bill for GIP
  • For prolonged services you MUST use “in and out” times- these are additive: ex: if you see a patient from 9:15-9:45 and again from 3-3:30; total time is 60 minutes

Here are some additional resources from AAHPM on billing:

AAHPM Quick Reference Billing Guide (2006)


Tanya Stewart MD FAAHPM

Preconference Workshop – Challenging Medication Management Issues at the End of Life

Henry the County Extension Agent was making the rounds of the feed stores when he ran into one of the local ranchers he hadn’t seen in a while. “Say, Jake,” he said, “I’m hosting a seminar next week over at the Grange and one of the experts from down at the University is coming in to talk about some new ideas that’ll surely make you a better rancher. Think I can count on you to attend?”
Jake paused a moment before he gave his thoughtful reply. “Not sure it wouldn’t just be a waste of time – I already ranch just about half as good as I know how.”
Perhaps in our more cynical moments we all feel a little bit like Jake. If you’re attending the Conference this week, then congratulations for bucking complacency. If not – well, we miss you.

I’ve always viewed the preconference workshops as a justifiable luxury. Some, like this morning’s ‘Building Effective Hospice and Palliative Care Teams,’ are just downright fun; others, like this afternoon’s ‘Challenging Medication Management Issues at the End of Life’ are considerably more academic. Unfortunately, the lack of access to handouts (they weren’t yet online at the time of the presentation) brings with it a difficult choice — listen carefully and pick up what gems you can, or scribe furiously, trying to get down data (and risk losing concepts.)

Anyhow, here are a few concepts that I extracted from the afternoon:

Drug-drug interaction effects can mimic imminent death (so can severe constipation). Elderly patients and those with organ failure have a combination of homeostenosis and a much narrower therapeutic range for many medications.
Interactions can be a result of either pharmacokinetics (CYP-inducers, e.g.) or pharmacodynamic.
Antihistamines (among a huge number of other medication classes) induce constipation. (Another reason for those of us sufffering from seasonal allergies to be miserable.) Hey, diphenhydramine lowers the seizure threshold, too.
PCA studies have shown that there is a 40-fold variation in need for opiates in post-op pain among individuals, all other things being equal. (But you probably wouldn’t get away with ordering ‘morphine 2-80 mg IV q 4 hours’.) Dose ranges are subject to interpretation by the nurse in any event, and there is no evidence that range orders really work to control pain. Consider something like ‘2 mg for pain less than 5 and 4 mg for pain greater than 5′.
Patients on multiple opiates pose a special challenge, but usually provide an opportunity for simplication. Do err on the side of lower in the case of long-acting opiates, and provide plenty of prn meds for breakthrough. Then reassess after a few days and consider adjustments in doses of long-acting agents.

—breaking news— The slides have just appeared online with two more
presentations to go. Better late than never?

Picking up again…
Methadone is a great drug for analgesia, but interactions with other medications are a big concern. QTc prolongation is also a concern, and attention should be paid to cardiac history and family history of sudden death.
Olanzapine works for nausea. (I did not know that…)
In nursing homes the abbreviation prn may mean ‘patient receives nothing.’ (I’ve never heard that one before.)
Changing a patient from another opiate to methadone requires a non-linear conversion. There are a number of different protocols which work, but the hallmark of any is that the patient be closely monitored during the transition, since respiratory depression may develop out of proportion to the analgesic effect. Adjustments more often than q 5-7 days probably have more potential for harm than good, so be sure that there is a reasonable breakthrough pain control strategy (prn methadone if in a closely monitored setting, otherwise prn narcotic of choice.)

All in all a great summary of some pharmacological concepts that I haven’t explicitly considered in some time. I’ve picked up a couple of new approaches to add to my pharmacologic armamentarium, and each time I hear the methadone pep talk I get a little more comfortable with a medication that I still treat with great respect. Maybe when I get home I’ll be able to practice a little more than half as good as I know how.

Michael Moffitt, MD, PhD
Scott & White Hospice
Temple, TX

Registration: Wednesday, March 3, 2010

I was very pleased that registration this morning was organized, efficient, and fast. I arrived at the registration area of the conference center around 7:45am (I may have slowed my stroll through the mall that is attached to the conference center for some window shopping prior to arrival). There was a line of about 25 people who had pre-printed registration forms (there is a separate line for those who do not have pre-printed registration forms). I had my badge, complimentary green bag, official Assembly guide and arrived at the Medical Directors Course by 7:55am! The people working at the registration table had smiles and were very cordial. The only suggestion I would make is to separate the two lines (for those with and those without pre-printed forms) further so they will not be intermingled toward the back, giving the appearance that some folks were “jumping” line. Overall, a good registration process.

Ann Cheri Foxx, MD

Entertainment Ideas for Boston

Welcome to Boston! If you have any questions about anything Boston related, stop by the Greater Boston Convention & Visitors Bureau Concierge Desk at the Hynes Convention Center located by AAHPM Registration during these times:

Wednesday: 9 pm-6 pm
Thursday; 9 am-4 pm
Friday, 9 am-5 pm
Saturday, 9 am-3 pm

Fenway Park is just down the street from the convention center, so be sure to ask about the 25% discount on Fenway Park Tours!

Looking for something fun to do?

Thursdays, 5-7 pm, Wine Tasting, 33 Restaurant

Fridays, 6:30 pm, Live Cooking Shows at Rustic Kitchen

Nightly Rush Hour Menu at Morton’s Back Bay…$6 Bar Bites all night!

Friday, March 5, 7 pm, Boston University Hockey vs. Northeastern

Friday, March 5, Pat Green in Concert at House of Blues Boston

Dinner and Jazz nightly at Beehive

America’s Oldest Restaurant…Union Oyster House

Top of the Hub…best views in the city

Additional questions

For additional questions, feel free to contact Lisa Deveney, Greater Boston Convention and Visitors Bureau,at Follow Lisa on Twitter, @LisaBostonUSA, for more ideas of evening events during the AAHPM & HPNA Annual Assembly.

Looking forward to seeing you all for a great meeting!

-Vanessa Mobley, AAHPM Senior Meetings Manager