Archive for March, 2012

Dual Diagnosis, aka Substance Abuse, Mental Illness, and Palliative Care

It seems innocuous, but the term ‘dual diagnosis’ describes a very complicated subset of patients — those who have a substance use disorder as well as a primary psychiatric disorder (anything from depression to schizophrenia). Throw a serious medical illness into the mix, and you have a recipe for one very overwhelmed palliative care physician.

Moving along, I’ve paraphrased key info from the case that was presented –

  • Presenters describing patient: “Opiate dependence, stopped methadone maintenance therapy, mood disorder, trauma history, cocaine, family estrangement, new cancer diagnosis.
  • Most of room: “This doesn’t sound good…”
Never fear, this patient is manageable! The most important thing is to recognize that a team approach is essential — involve psychiatry, social work, the patient’s outside providers, clinic staff, etc. Try proactive measures like a pain contract (though not infallible), and encourage the patient to bring her sources of support with her to appointments, whether they be friends or family.

  • Presenters: “Now she’s your patient and you’ve been noticing she’s missed a lot of appointments with you and her oncologist, she’s had a number of early pain med refills due to lost scripts and stolen meds, and she’s still having a lot of pain despite very high opioid doses. She refuses to switch over to methadone because she doesn’t like the side effects. Now what?”
  • Most of room: “Refer patient to someone else!”
    Wait! Let’s think about it first and consult with the interdisciplinary team. This is a patient who has had a long history of opioid addiction who is now back on opiates. Of course she’s going to fall back into addictive habits, so let’s figure ways to help the patient change some of those habits. But also don’t forget the phenomenon of pseudoaddiction, which is an iatrogenic syndrome of abnormal behavior that’s a direct consequence of inadequate pain relief.
    There are some strategies we can implement – prescribe only small amounts of opioids at a time, do pill counts, and get random urine drug screens (remember that standard UDS dont’t test for oxycodone, so you have to add that separately). Can we combine her psych/substance abuse counseling appointments with her already-scheduled palliative care appointments? And of course, ask the patient about her perception of the obstacles preventing her from full compliance (if you went to the Motivational Interviewing session, this is a perfect time to practice those skills).
    Now, say the patient is in remission, but still on high dose opiates due to continuing pain. Keep her on these? Since our ultimate goal is to manage pain while also optimizing function, we should probably wean her off the opioids. She’s wary of methadone, but lets explore those fears and discuss it with her substance abuse counselor. The addiction psychiatrist probably has some other ideas as well.
    This is the sort of patient who can be very trying yet ultimately very rewarding to work with. Though keep in mind that It’s especially important to have an outlet to vent the jumble of emotions that these patients stir up, which is another crucial function of the interdisciplinary team.
Erin Zahradnik, MD, Yale University Dept of Psychiatry

Driving Miss Daisy

You’ve all been there – the elderly couple shuffles into your office, peering through oversize glasses, slightly disoriented but helping each other out. Did you ever stop to think how they got to your office? They almost certainly drove – but should they? Shouldn’t it be their children’s job to tell them to stop?? Focus groups have shown that it’s the physician they look to for guidance (sigh).

Luckily, there are excellent resources to guide you in evaluating driving impairment and to let you know what the laws are in your state. Google “AMA older driver safety” for a wealth of information. It’s free and you don’t have to be an AMA member to access it. There are even disease-specific recommendations from areas as diverse as ophthalmology, cardiology, and neurology. The AMA also has an ethical opinion on impaired drivers and charges the physician with recommending driving restrictions and, if needed, reporting impaired drivers to the Department of Motor Vehicles (DMV).

Dr. Karen Cross recommends a 6-step approach. (1) Identify patients at risk of impaired driving; (2) find out if the patient is still driving; (3) assess their driving skills; (4) make recommendations with referral for a driving evaluation – try for resources; (5) counsel the patient about transportation alternatives; and (6) if all else fails, report the driver to the DMV.

A little more on identifying patients at risk of impaired driving. Driving requires vision, both peripheral and focal. It requires physical activity – from opening the car door to moving one’s foot from the gas to the brake. Reaction time is also important, along with memory and the ability to concentrate, especially when distracted. Many of these skills can be evaluated in the office or home setting. A driving evaluation may be useful when there is conflict over the patient’s abilities. Unfortunately, these are not covered by Medicare or most insurers and can be expensive.

Restricting a patient’s driving can be life altering, resulting in depression, social isolation, and impaired self-esteem. There’s even an increased risk of long-term-care placement if an elderly person can no longer drive to meet their daily needs. On the other hand, there is the risk of injury to themselves or others. It is a physician’s responsibility to make the tough call and recommend driving restrictions when they are needed. Remember to check the AMA website for state-specific tools to support your recommendations.

Safe driving!

The Why, How , What and “So What” of developing Clinical Informatics Tools

This am has been an interesting juxtaposition of following twitter during the state of the science, and being reminded of the power of a graciously led small group meeting.

I would not qualify myself as a skeptic, but more as a user without training in the multiple areas for which a Clinical informatics system can be adapted to improve our care, And having recently been faced with the common problem of being told the system at my new institution will take months to change, I was hopeful for new quick tools.

Joy Goebel, Kelly Chong, Sangeeta Ahluwalia and Karl Lorenz gave an organized presentation of the issues involved in the why, how what and so what of Clinical info tools.

We were reminded these tools and systems are very early in development and that the technology will progress even as we work to develop tools.

We were reminded of the need to work with stakeholders and end users to develop clinical information tools, and if the application of Implementation Science (a term I had not heard before).

Greater La VA system has a consult tool, but not other notes yet, and is just beginning to generate reports. They seem to have a great and very multidisciplinary development group, and I they may create national VA templates and reports that others can review. It had nice features like embedded tools like the PPS and embedded references which would be great for multiple users to help standardize documents.

There were many good questions asked about limitations, and I realize that the issue still returns to understanding my system and what its benefits and limits are. Any other Cerner users with templates for notes or ideas about how to highlight goals of care info in the large volume of documents generated?

I learned much from blogging, as it caused me to think and listen more critically. Thanks to the academy for the opportunity.

Diane Dietzen, MD Baystate Medical Center

Communication as a dance

Ok -so it only took me 40 min to post the first one so this posting will get better.

This session was about motivational interviewing and was led by Julie Childers and Bob Arnold. We were very interactive and engaged and it was very heartwarming to see a large roomful of colleagues who have really good communication skills but want to think critically about how to get better. One of the things this meeting regularly provides is that warming of the heart.


Techniques- we reviewed standard interviewing to prescribe change, and the spirit of motivational interviewing: curiosity, respect for autonomy, patient as expert, physician as consultant, collaboration and empathy. The OARS of motivation interviewing were described: O- open ended questions, A-Affirmations R –reflections and summaries.

The difference between following up with a question, or following up with a reflection was stressed .The reflection can add a little more of your assumption about what was said, and can advance the conversation, so it is a good technique to understand.

And then we practiced, and by reflecting had a really insightful discussion of creative outlets and how they relate to palliative care practice in a small group in a very short time.

I do agree with the comment made in the session that reflecting creates more vulnerability for you as an interviewer, but also for the patient. In practice the art is as always to balance reflection with questions or summaries, or silence.

In the discussion, issues of “agenda “and right and wrong” in meetings with patients and families and concerns were described. I think all of us have thought about and about the idea that in palliative care there is no right answer for a given patient or family , there are their answers which we may not agree with. If we find continued disagreement our job should be to find out why the patient/family is choosing the option they are and provide support.

Again valuable to add another frame to think about how we communicate, and how to teach this to others.

palliative care and wellness

Newly inspired by Christian Sinclair’s presentation I am happy I challenged myself to be a blogger at this meeting.

I certainly agree that the title “An unlikely union- Palliative Care and Wellness “seems apt, and quite intriguing. And at a session I attended yesterday the emphasis was on integrating palliative care, and so I was eager to learn how the framework of wellness care might fit.

Cobie Whitten, Becca Hawkins and Gregg VandeKieft did a great job of providing a framework for the discussion reviewing a little about chronic illness care, cancer survivorship, and models for care. The discussion was very lively


The language- there was much talk about the connotations of palliative care and wellness, and the hope that associating the two would further the overall discussion about quality of life. This despite the still difficult connotations of palliative care for some providers.

The need to address the cancer survivor population comprehensively and provide ongoing support- extending way beyond treatment. This likely involves better education of primary care providers about medical issues in follow-up but also other supports. Palliative Care providers can participate in developing this education.Creating a specific post treatment plan for education also seemed a good way to help convey this information to other providers caring for the cancer survivor.

We need to create these models for other populations like dialysis patients with models similar to many cancer centers and for the chronically ill in general. Other sessions here have addressed models for this type of ongoing wellness care.

The importance of rehab and nutrition in wellness, a point I have recently come to recognize in my palliative care practice.

What can I do to use this information? Colleagues at my new place of employment have shared with me their thought about an outpatient wellness center that includes palliative Care, but at present that is only one of those grand ideas. That is a grand 10 year plan. Perhaps sooner I can investigate with my cancer center colleagues and nephrologists wellness follow- up for their patients, and how primary care is involved.

So is this grand ides thought provoking for others – or have you had so many thought provoking new ideas in the last 24 hours that this still seems” unlikely”?

I will try to remain focused on more discussion of this, even with the 50 ideas I will add to my to do list next week.

Diane Dietzen, MD Palliative Medicine Physician, Baystate health, Springfield, MA

Chemo in the last 2 weeks of life

Chemotherapy is a two-edged sword. As an oncology trainee I’ve seen a few patients die solely because of it. And yet aggressive treatment is sometimes necessary to save a life; in the right settings it often succeeds. Patients with Hodgkins’ disease, testicular cancer, acute leukemias, and early stage colon, lung, or breast cancers, among others, are often cured because of chemotherapy and other aggressive treatments. Like any useful tool though, it must be properly applied in order to be effective and avoid harm. You wouldn’t use a screwdriver to drive a nail; similarly, chemotherapy shouldn’t be given to all patients in all situations, nor should it be a substitute for good discussions about goals of care and the likelihood of deriving benefit.

Yesterday’s cancer SIG presentation cut to the core of many issues that create tension between oncologists and palliative care clinicians. Most of us have probably seen difficult situations involving chemotherapy; it can be very upsetting! We tend to point the finger at oncologists when things go wrong, but we must recognize their unique perspective. To paraphrase one of today’s presenters, “Sometimes I can give a patient 5 different rounds of chemotherapy over 7 years and see them respond well each time.” In other words, chemo often really helps patients, even when its intent is palliative. I promise, we’re not monsters….oncologists are people too! :)

Data support the use of chemotherapy in a number of advanced disease settings, even many solid tumors. Yes, chemotherapy can and should be part of good palliation in many settings. There are significant symptom benefits, QOL improvements, and survival benefits to be had in cases of lung, breast, colon, and prostate cancer; many other solid tumors respond to chemotherapy as well. Of course, the devil is in the details. An emerging quality indicator in oncology practice is the proportion of patients receiving chemotherapy in the last 2 weeks of life. Too many patients are receiving chemo just before death.

Here’s the conundrum: we know chemotherapy can be beneficial, but only in certain settings. Unfortunately we’re not very good at predicting how well a particular patient will tolerate treatment, nor how well their tumor(s) will respond. How should we proceed?

The SIG speakers recommend following a framework: First, look to published guidelines like those from the NCCN, which tell us when chemotherapy is no longer recommended (link). If treatment is pursued, it must be done with full informed consent regarding its palliative intent. Treatment must be viewed as a time-limited trial, with specific criteria for measuring response and planned discontinuation if none is seen. Transitions to hospice should be discussed early, at the first signs of decline in function. And the palliative care team should be involved! As Dr. Smith pointed out, recent data on early palliative care in advanced lung cancer shows a resultant reduction in chemotherapy usage in the last 60 days of life. We still don’t really know how this works, but it works, and it doesn’t impair survival.

Going forward, palliative care will become more integrated into comprehensive cancer care, as per recent recommendations (link). This requires palliative care clinicians to better understand the role of chemotherapy as part of good palliative care for many cancer patients. Let’s be constructive, and increasingly work side-by-side with our oncology colleagues in caring for patients with incurable cancer. Hug an oncologist today! :)

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

Model for Running a Palliative Care Interdisciplinary Team Case Conference

Our palliative care interdisciplinary team (IDT) meets every morning, and reviews nearly all the patients on the inpatient service, new patients seen in the outpatient clinic, outpatients in need of active management of some aspect of their care (typically pain medication), and patients under our care who have died. It’s a unique and comprehensive meeting that gives us the opportunity to hear about each of our patients from the beginning of our interactions with them, making transitions between providers and location of care much easier than what I am accustomed to. I haven’t seen other IDTs in action so I was curious to see how other programs do it. As it turns out, the Mt Sinai team presented a model not just for an IDT meeting, but specifically how they do their weekly case conference.

They have developed a highly structured model for presenting a pre-selected case to their interdisciplinary team, called “Bring it to the table” (BITTT), referring to the goal of presenting cases that bring a need for help with a tricky management issue, interpersonal dynamic, or with learning potential. Under their old system, they found that the medical side tended to dominate the discussion, and part of the motivation for revamping their conference was to encourage greater participation by the non-medical members of the team. To that end, the facilitator for their conference is typically their chaplain. There are time limits placed on each section of the conference, with time for the clinical case presentation, clarifying questions from the group, and group discussion. This has improved attendance and participation in their conference, and particularly participation by the non-medical members of the team as there is time dedicated for them to ask questions. The time limits imposed also allow for two case presentations weekly, one by each consult team.

As part of the structure of their conference, the facilitator asks the presenting team: “You bring this case to the table because…” with the team filling in their reasoning. I loved this question, because it does force the presenter to be thoughtful and focused on what they are hoping to accomplish with their presentation. This was a very common theme when I was a chief resident and helping residents to prepare for their M&M presentations, when they often chose cases that were extremely complex past the scope of what could be presented in an hour, and needed to identify what specifically they were trying to communicate to the audience. This skill of identifying your teaching (or learning) objective is not intuitive to all learners and educators and I think is really critical for those of us entering the world of clinical education. I love the explicit emphasis placed on it by the Mt Sinai team. My team does some case presentations in our weekly palliative care conference, and while I think the strict structure of the BITTT model does have some drawbacks, it’s worth considering for us as our section grows and the potential for conference chaos increases.

Does your program have a regularly scheduled case conference? How does it work?

Meredith MacMartin, MD, HPM Fellow at Dartmouth-Hitchcock Medical Center

Concurrent Session – Delirium

Trust psychiatrists to give an afternoon session that makes you completely forget about that nap you were craving! “Delirium: A Study of Difficult Cases” consisted of 3 vignettes about various forms of delirium, complete with very realistic role playing and chock full of wisdom from palliative care psychiatrists.

First there was a case of reversible hyperactive delirium. We were reminded that just about anything could be the culprit behind it, including common HPM meds like opioids and benzodiazepines, minor infections, metabolic derangements, and overstimulating environments.

How to treat the agitation in reversible delirium? First try to reduce stimulation and create a soothing environment. Can you eliminate any unnecessary meds? AVOID benzos! Use 1st generation antipsychotics such as haloperidol or chlorpromazine (more sedating than haloperidol), and dose the way you would dose pain medications.

What about irreversible delirium? This is the kind that occurs during the dying process, so a good clue that it’s not reversible is that there will be physical signs of dying. In this case, you can use antipsychotics, but you could also use benzos like lorazepam or midazolam. Remember that the goal is to reduce suffering by reducing the agitation of delirium — this is NOT palliative sedation, this is medical managment of a medical symptom.

Sometime benzos won’t be effective, and in those rare cases you could try propofol or phenobarbital. The key point is to treat agitation like a breakthrough symptom.

The final vignette illustrated a case of mixed delirium in pediatric palliative care (complete with role playing where the parent was as much the patient as the kid). Yes, delirium happens in kids too! This is a sneakier form of delirium (and can happen in adults too) that presents with waxing/waning symptoms. The gist is that you treat kids the same as adults (though with lower doses) — haloperidol and risperdal (both antipsychotics) are effective and safe in kids and infants.

I left with the understanding that delirium is a form of suffering, and as patients who come out of it later say, is a terrifying and disorienting experience. Treat it proactively and don’t hesitate to consult psychiatry for tough cases!

Erin Zahradnik, MD, PGY-3 Yale University Dept of Psychiatry

“Bending the Cost Curve:” reflections on this morning’s plenary session

America, your bluff has been called…the verdict is in, and the old adage remains true: you cannot have your cake and eat it too (shocking news, I know). Clichéd as it may sound, that message rang true this morning as the annual assembly opened in a blaze of introspection and criticism of the status quo. The target? Rising healthcare costs. Even current levels of U.S. healthcare spending are unsustainable, yet we continue on a path of rising costs without adequate thought regarding the value of care provided.

The panel discussion featured Thomas Smith, Brad Stuart, and Rebecca Kirch, each presenting perspectives on the problem and fielding questions. Smith hit the nail on the head, pointing out that “value is missing, care is not optimal, and costs are rising unsustainably.” He highlighted some staggering statistics from a sample of cancer patients at a major academic medical center (Dy, et al, 2011). Roughly 1/3rd received chemotherapy within 2 weeks of death, ~25% ended up on a ventilator, less than 1/4th were discharged to hospice care, and ~1/3rd died in the hospital. Quite a sad state of affairs! Yet insurance premiums are rising quickly, having doubled between 2000 and 2010; herein lies the “missing value.” What are we buying with all this money spent? What’s a society to do?

At this point someone usually drops the “R-bomb,” which can curtail any meaningful debate. Imposing limits on healthcare is such a charged and seemingly un-American idea. Must rationing be the only solution though? Per Brad Stuart, the answer to this question is a resounding “no!” Stuart described a program called AIM (Advanced Illness Management), which effectively turns this debate on its head. Rather than focusing on imposing limits, AIM emphasizes the importance of eliciting and defining patient preferences early (and often), and facilitates doing this in the community rather than just the hospital. AIM data show how this approach can yield improved outcomes, higher quality of care, and even decreased costs!

This sounds like what many of us in palliative care already think we do; we’re communicators, goals elicitors, and compassionate caregivers. But we are handcuffed by a system that often views us as the alternative to aggressive treatments, especially in cancer care, and we’re often involved too late in the process. Thankfully, this too is changing. A recent guideline from the American Society of Clinical Oncology recommends early palliative care for all patients with advanced cancers (link). Palliative care is increasingly viewed as a part of the solution and a part of quality cancer care, rather than an adversary.

In this climate, 2012 is a time of enormous excitement for our field! How we brand and conduct ourselves though, is crucial. We must be partners in cancer care, not antagonists. As Kirch taught us in reviewing the CAPC report, how we talk about palliative care truly matters; if we do it “correctly,” patients are overwhelmingly interested in what we do, and would want it for their loved ones (link).

As a trainee in both oncology and palliative medicine, I cannot imagine a more exciting time to be working at the intersection of these fields. Let’s continue to work together to blaze a trail towards increasing quality of life and quality of cancer care. In line with the AIM program, and those like it, let’s be champions of patient choice, rather than reapers of grim. Palliate early, and often!

Thomas W. LeBlanc, MD, MA
Fellow, Medical Oncology and Palliative Medicine
Duke University

AAHPM pre-conference workshop: Junior faculty bootcamp

“Early Career Hospice and Palliative Medicine faculty Development Bootcamp”: Drs Bernacki, Carey, Sanchez-Reilly, Periyakoil, Kapo, DeLima Thomas, Morrison, and Bunch O’Neill

I was a little apprehensive about this workshop, since I’m still a fellow and not even junior faculty yet. I will be taking a faculty position when I finish my fellowship, so I figured that whatever I learn will still be applicable four months from now. I think many trainees wonder what it means to be an attending, and especially about the mysterious “non-clinical time” (which residents and fellows get just enough of to know that we probably want more of it!). I do know enough to know that it will be different than anything I’ve done so far, in terms of work-flow, responsibility, and expectations. To add to my uncertainty, I am joining our section as part of a significant expansion which will mean changes in how the entire section functions. I was hoping for some strategies to manage what feels at times to be a monumental task, and I was not disappointed.

We started by creating mission statements for ourselves: short, using active language, and focused on what we want to achieve and why. My mission statement: To improve medical care by expanding palliative care education at all levels. It was really inspiring to see how big we are dreaming! Other topics covered included time management (oh Covey square, where have you been all my life?) and conflict resolution (both in the context of patient interactions and with professional colleagues).

When we talk about interactions with patients and families, we often talk about being intentional in our approach, to be mindful and centered in order to function most effectively. What I am taking home from this workshop is a greater sense of intention as I start my career, with my specific goals in mind and a much greater awareness of my own strengths as a palliator and as a faculty member. I was also really struck by the obvious camaraderie between our presenters, and the strength they derived from having a peer mentoring group. At our table we had a wonderful group of people and it was both somewhat therapeutic and also really fun to share stories about challenges in each of our lives. It was really striking how the same themes kept coming up over and over again across the whole group. Take home message: it can be hard to be a junior faculty member, and what you’re going through is normal!

I walked out of the workshop focused on my goals, inspired to implement some of the tools we learned, and feeling more confident in my ability to shape my career to match my vision. I am really looking forward to the rest of the conference, meeting more new faces and getting more inspiration for what I already consider the greatest job there is.

Meredith MacMartin, MD, HPM Fellow at Dartmouth-Hitchcock Medical Center