Archive for September, 2010
In an effort to keep you on the edge of your seat, I am finally posting my last summary of Board Review Course – day three! Of course the delay has nothing to do with the craziness of my life and the concept we refer to as life-work tight rope walking. Balance is a bit out of the equation right now.
That aside, here are some highlights from the last day…
Hospice Medicare Benefit (Bruce Chamberlain)
- Understand the benefit periods and timing of when IDG must review each patient
- Understand the difference between revocation, transfer and discharge
- MD must be actively engaged in the Quality Assurance Performance Improvement (QAPI) program- where the hospice actively measures, analyzes and tracks quality indicators
- What are the different levels of hospice care?
- What are the medication review requirements under the new COPs?
- How many medical directors can a hospice have?
Hospice Eligibility (John Manfredonia)
- At initial certification the attending physician and the hospice medical director must certify the patient’s prognosis is likely less than 6 mo
- At recertification only the hospice medical director needs to make this statement
- After January 1,2011- hospice MD or NP must have a face-to-face encounter with each hospice patient within 15 days of recertification prior to the 180th-day certification and each certification thereafter (may be too new to be on this exam- but who knows??)
- Physician narrative for certification is mandatory
Prognosis (Joseph Shega)
- MDs overestimate prognosis in general
- Cancer: if pt spends 50% of time in bed, px about 3 months
- COPD- BODE index can be helpful when evaluating severity of disease and justifying keeping a patient on hospice
- Hepatorenal syndrome supports <6mo px in ESLD
Billing (Bruce Chamberlain)
- GV modifier used by the attending of record- who is NOT the hospice medical director when billing for any care
- GW modifier used by physician for billing unrelated to hospice diagnosis
- Hospice medical director never uses GV modifier, even if he/she is the attending of record
- Hospice medical director cannot bill for plan of care oversight
- Any physician other than attending of record, seeing the patient for issues related to the patient’s terminal diagnosis must have a contract with the hospice- and bills the hospice directly
Discontinuation of Technological Support (Joseph Shega)
lots of links to Fast Facts and Concepts
- Withdrawal of the Ventilator
- Symptoms with Ventilator withdrawal
- Key points of Artificial Nutrition and Hydration
- Dialysis Withdrawal
- Symptoms with Dialysis Withdrawal
Goal Oriented Decision Making (Sean Morrison)
- 8-Step Protocol for Negotiating Goals of Care
- What is the differential diagnosis of conflict
Other fascinating discussion in this lecture was unrelated to the boards- but still worth your time: NPR interview with NYU historian Tony Judt
And that’s the summary… Keep the engines running… November 16th, is just around the corner!!
Tanya Stewart MD FAAHPM
Mucositis is a frequent problem encountered by hospice and palliative care services. Its treatment remains a major focus of holistic and medical therapy. Mucositis is found among 40-50% of patients receiving standard chemotherapy or head / neck radiation. This percentage is nearly doubled for bone marrow transplant patients. It can occur as a direct consequence of the radiation or chemotherapy or indirectly from infections compounding immunosuppression. Once the offending agent is stopped mucosal integrity gradually returns. In the meantime the inflammatory pain reduces the patient’s quality of life while also decreasing their oral intake leading to dehydration and malnutrition. Magic mouthwash, known by many names and aliases, reduces the pain, the disability of mucositis. Its basic constituents are as follows (1);
1) A topical anesthetic (eg. an antihistamine to reduce pain).
2) An antibiotic or antifungal.
3) A corticosteroid to decrease inflammation.
4) An antacid to coat and protect the mucosa.
The type and quantity of the constituents will vary according to the practitioner and their locale. Some common recipes are as follows (2,3);
University of Florida
60 ml Benadryl (liq)
60 ml Viscous Xylocaine
60 ml Nystatin
60 ml Maalox
sig 5 ml swish / spit q2 hrs prn
Mary’s Magic Potion
240 ml Benadryl 12.5 mg / 5 ml
1.5 grams Tetracycline
6 million units Nystatin
60 mg Hydrocortisone
sig 5 ml swish / spit QID
Weisman’s Philadelphia Mouthwash
160 ml Distilled water
80 mg Hydrocortisone
80 ml Maalox
sig 5 ml swish / spit QID
100 ml Cherry-flavored Kool-Aid mixed w/ 2000 ml distilled water (sugar- free)
100 ml Viscous Xylocaine 2%
100 ml Nystatin
sig 15 ml swish / spit or swallow QID
20 ml Benadryl 12.5 mg / 5 ml
150 ml Viscous Lidocaine 2%
2 grams Tetracycline
20 ml Nystatin
100 mg Hydrocortisone (Solu-Cortef)
sig 15-30 ml swish / swallow q4-6 hrs
Data are scarce supporting the efficacy of the individual components (especially the steroids and the antibiotics) in the treatment of mucositis. However, for many of our patients who suffer from the debilitation of mucositis, the relief that this concoction offers has earned their faith and our respect.
Robert Killeen MD
1) Moynihan T. Magic Mouthwash; Effective in Treating Chemotherapy Mouth Sores? MayoClinic.com – 10/31/09.
2) Tom WC. Magic Mouthwash. Pharmacist’s Letter / Prescriber’s Letter. 2007;23(7):230703.
3) Covinsky K. Management of Mucositis: Requesting Your Wisdom. Geriatrics and Palliative Blog – 7/8/10.
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/.
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.
- 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.
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.
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