Archive for September, 2013

Highlights of the September Issue of the Journal of Pain and Symptom Management (JPSM)

Listed below are a few articles from the most recent issue of the journal:

Rehabilitation in Advanced, Progressive, Recurrent Cancer: A Randomized Controlled Trial
Louise Jones, Gail FitzGerald, Baptiste Leurent, Jeffrey Round, Jane Eades, Sarah Davis, Faye Gishen, Amanda Holman, Katherine Hopkins, and Adrian Tookman

Intentional Sedation to Unconsciousness at the End of Life: Findings From a National Physician Survey
Michael S. Putman, John D. Yoon, Kenneth A. Rasinski, and Farr A. Curlin

Parents’ Perceptions of Their Child’s Symptom Burden During and After Cancer Treatment
Lena Hedén, Ulrika Pöder, Louise von Essen, and Gustaf Ljungman

To access the articles, you must subscribe to JPSM or be a member of the American Academy of Hospice and Palliative Medicine (AAHPM). For further information on the Academy, call 847 375 4712 or visit aahpm.org.

Submitted by: David J. Casarett, MD, MA, Senior Associate Editor, JPSM

Education Resource Email #5: Fast Facts and Concepts

Fast Facts and Concepts for Ed-SIG

http://www.eperc.mcw.edu/EPERC/FastFactsandConcepts

Fast Facts and Concepts (“FF”) are a series of short, peer-reviewed monographs on a wide variety of palliative care topics. They are published on the EPERC website at the Medical College of Wisconsin, as well as co-published in the Journal of Palliative Medicine. FF were started in around the year 2000, as part of the Robert Wood Johnson Foundation palliative care residency education project that David Weissman MD ran. Drew Rosielle MD has edited them since 2007, with assistance from Sean Marks MD since 2013. More information about the editorial board and process is available on the FF website.

Using FF as an educational-resource.


  1. FF are developed to be practical & clinically relevant point-of-care resources. We write/edit them with residents in mind, although we hear that they are used widely by medical students, residents, attending & faculty physicians, nurses, social workers, and administrators. They are aimed at non-palliative specialists, but would be relevant for palliative learners such as fellows, especially in the first 6 months. The idea behind FF is to give the reader both a broad overview of a topic, as well as practical tips in approaching a patient or certain situation, whether it is extubating a patient to ‘comfort care,’ going into a family meeting one worries is going to be contentious, to seeing a cancer patient in clinic who complains of severe fatigue.

  2. FF are based in evidence, as well as evidence-based. While always peer reviewed, as FF (and the field of HPM in general) evolved, it became more important for them to be evidence-based. The current editorial stance is that they have to be as evidence-based as much as there is evidence, and transparent about the level of evidence behind any recommendation. That said, much of our practice remains empiric, and we continue to believe there’s a role for common sense and the wisdom of clinicians, and FF include a lot of that, as well. They are ‘evidence-based,’ insofar as they’ve been investigated and shown to improve medical resident’s palliative knowledge (http://www.ncbi.nlm.nih.gov/pubmed/21395446).

  3. Ideas for using them as teaching tools:

    1. When working with learners on, for instance, a palliative consult service, have them pull 2-3 relevant FF for each new patient they see and share them with peers on the team each morning after rounds (etc).
    2. Use them for ‘academic detailing.’ A colleague asks you why you do something, give them the FF as a starting point.

  4. FF for fellows:

    1. FF are peer-reviewed, and published in an indexed journal, and are great scholarly project for fellows. Ask anyone who has written one, the editorial process for them is demanding and meticulous.
    2. If a fellow is interested in writing one, please make sure they contact Drew Rosielle (rosielle@umn.edu) before starting. There are 10+ being worked on at any given time, and so fellows should make sure it’s not a ‘spoken-for’ topic before starting work.

Puzzles with Missing Pieces

In my first year as attending physician in a large homecare-based hospice, I have encountered many personal and professional struggles. The biggest of these for me has been that of accountability. Having trained in a tertiary care center where most everyone comes through the emergency department, there is information galore on each palliative care and hospice patient. Recent scans, labs, consults, and evaluations are all in one glorious EHR. With one passcode entry, I have every piece of information I need to make smart, informed decisions with just about any patient. The physical exam mattered little when I could tell Mr. Smith with certainty that his CT showed a mass. I long for those days.

With my home-based hospice patients, I have some information in most cases, but in all cases it is fragmented. Patients see their PMD on occasion, but see the GI specialist for their bowel troubles, and the cancer center across town for their neoplasm. They all use a different EHR, if they use one at all. In my office, I get facsimile copies of a truncated recent history; hyperlipidemia management notes from primary care, colonoscopy notes from GI, and hand-written nursing notes from the last hospitalization, none of which add up to the complete picture of whom my patient is today. As an aside, I am sometimes taken back to my residency days when I would hold the chart at arms’ length and squint my eyes to make out a lazy physicians’ hand-written consult note. These days, if I’m really interested in what the note says, I sometimes concentrate as if it were one of those 3D “Magic Eye” pictures that suddenly appears if you do it right. Rarely do I have that kind of time (or patience) anymore. Occasionally, I’ll get a patient who hasn’t seen a doctor in decades but who is obviously dying. What they are dying of is unfortunately anybody’s guess.

Hospice patients present tougher challenges than the inpatient or recently discharged. The hospice patient with biopsy-proven cancer who follows a normal end-of-life trajectory is thankfully, the norm. There is a subset of hospice patients however, who come into program with a life-limiting illness that follow an unusual trajectory. Mrs. Smith, for instance, came onto hospice with COPD, but with the question of a lung mass that was tentatively identified on CT. Mrs. Smith refused bronchoscopy or biopsy and did not wish to talk about what may be a cancer. Three months after I received Mrs. Smith on hospice, she became paranoid and confused. Unfortunately, this lasted for several months, which, in retrospect, speaks for itself. There were oddities along the way; urinary retention, rectovaginal fistula, VRE; all in the setting of normal lab values and a patient who didn’t want to know more.

As we all know, there is a lot of financial pressure that comes with being a hospice provider. There are no CT scans in home hospice. It can be difficult to put together a reasonable story that ties all the symptoms together when they just don’t make sense. It is even harder to look a family in the eyes and say, “I have no idea what’s going on.” I’ve found that the bridge to this particular gap is accountability. I may not have the answers, but I want to be there with each new development to tell them so.

As doctors, we are supposed to have all of the answers. In truth, the fact that I often don’t can weigh on me personally.

As HPM providers, we are the few who walk with patients and families through the unknown. We put pressure on ourselves as a specialty to be the providers who can ameliorate most of what ails you. Sometimes it feels as if this pressure can be too heavy for my young shoulders. I can’t always fix it. I don’t always have the answers. But I vow to be there to tell you that myself.

Bethany C. Calkins, MD
@MickeyMD913