Posts tagged palliative medicine

HPNA/AAHPM Collaboration for Annual Assembly

For the past 6 years, AAHPM and HPNA have collaborated to provide an annual conference for members of the interdisciplinary team. As we would expect, the outcomes have improved annually. Last year’s conference in Boston, recorded the highest attendance, the most satisfied attendees and highest rating for presenters.

Is it possible to improve? With any process, there are always opportunities to improve. This year’s conference committee co-chairs and more than 60 volunteer committee members have been committed to raise the bar even higher. HPNA will be kicking off a year-long celebration of their 25th Anniversary with many specialty events so we encourage you to come see, enjoy, network and grow professionally. While there, ask about the Hospice and Palliative Nurses Foundation walk-a-thon. It is a great way to exercise and support grants, scholarships and awards in research and education. See you in Vancouver, B.C. – remember your passport!!

AAHPM’s First RFS Representative’s Perspective on AMA Interim Meeting

My name is Devon Fletcher. I’m a Hospice and Palliative Medicine Fellow at the Virginia Commonwealth University Health Systems in Richmond, VA.

I recently had the opportunity to attend the American Medical Association’s Interim Meeting in San Diego this November as the AMA’s first ever AAHPM representative to the Resident and Fellow Section (RFS).

I’d been fairly active in the Medical Student Section (MSS) of the AMA during medical school but after moving to a new place and trying to focus on residency it ended up being years since my last AMA meeting. When I heard about this opportunity to rejoin the AMA I jumped at the opportunity to be more involved in organized medicine again.

Going to these meetings can be a little daunting the first few times. Things move fast. There are a lot of acronyms and abbreviations that get thrown around about which I had to refresh my memory! There has to be a “game plan” going in. It’s like a bee hive: People coming and going, everyone on their own little mission for the good of the whole. As part of the RFS, as in the MSS, I was again impressed with the number of articulate, dedicated hard working young residents and fellows working to improve health care delivery for our patients and for the working conditions affecting physicians.

Elected delegates from the MSS and RFS bring forward opinions from these sections to the House of Delegates Meeting (HOD) a few days later. Even with my previous experience with the AMA, I was reminded at how vast the medical community is across the nation. Being able to participate in a national debate with opinions from a wide variety of physicians and providers from around the country is incredibly eye-opening experience. It is important to understanding the common issues we face as physicians and discussion concerning how we can face these problems as a group.

Of course there were plenty of educational opportunities including a session on advance care planning —which just so happened to be led by one of the doctors from my medical school training in Jackson, MS.

The RFS is split into “regions”. Regions 1-7 are basically geographic sections. Region 8 is the subspecialty section with representatives from many of the major medical subspecialty societies across the nation. Our specialty section would like to have a conference call/tele-meeting to just discuss the issues going on with each field … really just for our own education. If any AAHPM members have anything they want other fields to hear or know about hospice and palliative medicine or there are major topics you would like to bring up that affect our field, get in touch!

If you want to get involved for the upcoming meetings you could also apply for an At-large delegate position!

More on the AMA-RFS 2010 Interim Meeting.

Happy 100th Anniversary, PC-FACS

The 100th issue of PC-FACS, an AAHPM signature service, represents a milestone. Celebrating this century issue, Editor-in-Chief Amy Abernethy commented on trends in palliative care since the digest’s inception. Read the 100th issue of PC-FACS.

(1) Increasing acceptance of palliative care as a discipline. The palliative care philosophy now extends into diverse settings including mainstream medicine. Once identified with end-of-life care, palliative care now defines care delivered appropriately throughout complex life-threatening illnesses.

(2) Systematic development of an evidence base, and iterative refinement of a toolbox, for palliative care practice. Research now includes rigorous randomized controlled trials and systematic reviews as well as observational studies, and addresses a wide spectrum of clinical issues and outcomes ranging from quality of life to health service utilization.

(3) Basic science exploration. Complementing clinical studies, basic science can provide insights into, and a biological underpinning for, clinical observations. Bidirectional conversation between basic scientists and clinicians will help develop, evaluate, and refine the next generation of interventions, and continuously improve quality and outcomes.

(4) Examination of quality. Efforts to define quality will allow us to benchmark clinical practice, advance/improve standards, identify effective approaches, and disseminate best practices.

Academy Voices Vital Role of Palliative and Hospice Care in Improving Quality of Health Care

Many health care initiatives launched by the Affordable Care Act focus on improving the quality of health care. The Academy and its members have been participating in these efforts, trying to bring wider visibility to the role that palliative care and hospice care can play in improving the quality of health care for patients with serious, advanced illness. Here’s a brief recap of some of the recent activity:

  • The Palliative Care and End-of-life Care workgroup of the National Priority Partners, (convened by the National Quality Forum), held an all day workshop on November 2 to come up with priorities to promote the diffusion of palliative care throughout the health care system. Numerous AAHPM members either presented or participated, including Sean Morrison, Sarah Friebert, Javier Kane, Karl Lorenz, Christine Ritchie, and Joan Teno. Diane Meier presented the opening overview, examining the current state of palliative and hospice care services and opportunities to improve access and close performance gaps. The speakers’ slides are posted on the NPP website.
  • AAHPM submitted comments to the Secretary of HHS on the National Health Care Quality Strategy and Plan. AAHPM’s public policy advisors see this plan as a critical document that will likely guide how federal energy and resources are spent over the next several years. AAHPM’s comments (which other Hospice and Palliative Care Coalition member organizations also submitted) made two main recommendations:
    • Add focus on patient-centered care guided by palliative care principles to measurement and accountability for all providers serving seriously ill patients.
    • Assure that specialty level palliative care and hospice services are broadly available and of demonstrably high quality.

Specific actions needed to achieve the above goals were also specified.

  • AAHPM also submitted comments (as part of the Hospice and Palliative Care Coalition) on the National Quality Forum measure gap agenda. Incredulously, the committee that ranked priorities for measures needed over the next few years ranked palliative care LAST. It received ZERO votes! The Coalition said in its comments: “the Coalition urges the NQF to recognize the urgency of making palliative care measures a high priority on the national measure development agenda.”

AAHPM’s Quality Task Force, chaired by Sydney Dy, would appreciate hearing from you about how we are articulating the need for quality palliative and hospice care. Please leave a comment and let us know whether you think we are succeeding in making the case.

Magic Mouthwash–The Last Snake Oil

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

Mile’s Solution

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? – 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.

Palliative Care Grand Rounds 2.9

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

Marten Creek Photo by Joan Robinson RN CHPN Seattle WA

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:

Other great bits

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.

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.

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.

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.

Some humor

Oscar the Cat - Photo by Stew Milne of AP.

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.

Check out next month’s host the SWHPN blog called palliative-sw. They have a new look!

PCGR has subscription options; you can follow by email or RSS feed. An aggregated feed of credible, rotating health and medicine blog carnivals is also available.

Day Two of Intensive Review…

The second day was just as intense as the first- fabulous speakers and a review of important information.
Here are some pearls from the second day of AAHPM board review course:

Dyspnea: (Vincent Jay Vanston)
-Total Dyspnea has 4 domains: Physical, Psychological, Interpersonal, Existential
-Must address all domains to adequately control Dyspnea
-When possible and appropriate, treat the underlying medical cause of dyspnea
-Opioids remain the front line agent for symptom relief
-Little support for benzo’s as front line agent
-Benzos and Opioids used together provide best effect when treating dyspnea

Nausea and Vomiting (Joseph Shega)
-Four pathways of Nausea- chemoreceptor, cortex, peripheral and vestibular
-No medications directly affect the Vomiting Center in the brain
-Know what drugs work on what receptors

Anorexia and Cachexia (Jennifer Reidy)
-Multiple factors contribute to ACS: tumor by-products, chronic inflammation, metabolic/neuroendrocrine/anabolic derangement
-Understand secondary causes of ACS (ex: oral problems, psychosocial issues, functional issues)
-ACS also occurs in non-cancer states such as with cardio-pulmonary disease, CKD, liver disease etc
-Understand difference between ACS and starvation
-Artificial Nutrition and Hydration (ANH) is not food, but medical therapy
-Purpose of ANH is not to improve comfort

Urgent Medical Conditions (Jennifer Reidy)
- Bowel Obstruction med management with analgesics, antiemetics and anticholinergics; anticholinergic drug of choice is glycopyrrolate 0.2mg-0.4mg sC Q6H or 0.02mg/hr infusion; drug of choice as it does not cross the BBB
-Spinal Cord Compression med management with high dose steriods; consider surgery +/- radiation therapy- good topic to look up in detail!!
- Seizures: status epilepticus defined as any seizure exceeding 5 minutes OR two seizures in 30 minutes without recover of consciousness- mortality 21-33%! those at risk: brain tumors, hemorrhagic stroke, h/o seizure, alzheimers, alcohol or drug abuse (w/d risk), liver/renal failure, lyte abnl, neurodegenerative dz, infections
-Seizure medical treatment options: subcut midazolam or phenobarbital; rectal diazepam (most antiepileptics can be given rectally); intramuscular lorazepam, midazolam or phenobarbital; sublingual lorazepam, clonazepam or midazolam; intranasal midazolam

Other topics discussed on day two: depression, delerium, other medical emergencies such as increased ICP/ pathological fractures and hemorrhage, palliative sedation, wound care, dementia, advanced cardiopulmonary disease and care of the imminently dying.

Suggested articles:

1. Abernathy A, Wheller J.Total Dyspnea. Current Opinions in Supportive and Palliative Care, 2008, 2:110-113
2. Del Fabbro E, et al. Symptom Control in Palliative Care- Par II: Cachexia/Anorexia and Fatigue. J Pall Med, 2006, Vol9 (2): 409-21
3. Ripamonti C, Mercandante S. Pathophysiology and management of malignant bowel obstruction. Oxford Textbook of Palliative Medicine, 3rd Edition. Doyle D, Hangs G, et al., eds. Oxford: Oxford University Press; 2003:8:496
4. Abrahm JL, Fanffy MB, Harris MB. Spinal cord compression in patients with advanced metastatic cancer: “All I care about is walking and living my life.” JAMA 2008; 299(8):937-46
5. Stewart AF. Hypercalemia associated with cancer. N Engl J Med 2005;352:373-9
6. Kovacs CS, MacDonald SM, Chik CL, Bruera E. Hypercalcemia of malignancy in the palliative care patient: a treatment strategy. J Pain Symptom Management 1995; 10:224-32
7. Wood, GJ, Shega JW, Lynch B, Von Roenn JH. Managemetn of intractable nausea and vomiting in patients at the end of life. JAMA 2006. 298 (10): 1196-1207

Other resources: website gives nice medication conversions

My thoughts on the final day at the review course will come shortly….

Tanya Stewart MD FAAHPM

“Two Days in the Joint”: A Visit to the Joint Commission

I had the privilege to represent AAHPM at the 18th Annual Liaison Network Forum at The Joint Commission (JC) headquarters in Oakbrook Terrace, Ill. I suspect many of us, in our professional career, have some hesitancy when approaching the JC but the “newer and friendlier” JC have some progressive, visionary work for the future of healthcare. It was a two-day conference and networking opportunity for 70 invited representatives from a diverse healthcare contingent representing a variety of organizations from the American Hospital Association, to the CDC to the Undersea & Hyperbaric Medical Society, Inc. All a friendly lot and it was very nice to see the AAHPM represented.

The JC enterprise actually has three divisions: the Joint Commission is the certification and accreditation company which is most familiar to us as the auditors showing up at our institutions doorsteps, The Joint Commission Resources which addresses safety and quality, nationally and internationally ( 41 countries so far) through provisions of education, publications , consultations and evaluation services, and the Center for Transforming Healthcare, a newer 501 C3 company which serves to offer solutions through setting up collaborative performance improvement projects with healthcare organizations in order to disseminate effective, durable solutions to the world.

The keynote plenary for the conference was given by Mark Chassin MD, MPP, MPH, President of the JC. In a nutshell, he set the stage for the future vision of the JC which is to transform healthcare into a “High-Reliability Industry” much like nuclear power and commercial air travel, which have highly effective process improvement and fully functional safety cultures. So a “simple” formula:

Robust Performance Improvement (RPI) + Safety Culture = High Reliability.

RPI involves systematic, highly effective strategies and tools for solving complex problems. Sort of a dynamic, continuous “root cause analysis” over time. RPI’s work to solve both routine processes like hand washing AND rare adverse events like wrong site surgery. Jerod M. Loeb, PhD the JC Executive VP for Quality Measurement and Research, points out that organizations must understand specific causes of problems they are trying to fix and then target interventions to those causes. He goes on to say the real challenge is the solutions (“Best Practices”) developed through this process may not work for all organizations across the board. Therefore the JC is suggesting “re-tooling” (the new buzz word) already established measures. Their newly published NEJM article (see reference below) summarizes this concept well.

Developing a Safety Culture involves trust, reportable, and appropriate use of RPI’s. The JC pointed out it’s not about developing a “blame-free “message but developing a culture that can separate small errors (blameless) from egregious(blameworthy)ones. The “Swiss Cheese Model”of assessing errors in healthcare that lead to harm was discussed extensively with emphasis on institutions assessing errors systematically, and establishing one code of behavior for all.

With all the “Big Picture” discussion at the conference as noted above, where did Hospice and Palliative Medicine fit in?
1) All issues mentioned above are important to HPM including RPI and Safety.
2) The attendees networking opportunity reinforced the support we have from a multitude of groups including the AHA, Critical Care Nurses, Critical Care Medicine, Pediatrics, the ANA, Physician Executives, Healthcare Executives, Nurse Practioners, Professional Chaplains, Women’s Health, the VA, Oncology Nursing, National Association of healthcare Quality.
3) The JC supports hospice care essentially by reinforcing the Hospice Medicare Benefit Conditions of Participation. They had no comment on the potential COP’s for face-to-face physician/NP visit mandates.
4) The JC supports palliative services and noted they were involved in standards development in the past but stated after this summer’s board meeting, they are still reluctant to develop a certification/accreditation process because they do not see any “ownership in the service” referring to funding support like CMS, Private Insurer, etc. They noted needing more “proof of sustainability” in order to move forward with certification. They agreed to listen to any input on this issue.
5) “Hand-off” communication in hospitals as patients move through different services was a hot topic and one HPM can make impact through a continuum of care model.
6) Unlike hospitals, long term care currently has no universal, comprehensive pain assessment standards.
7) The JC is reluctant to establish standards for chaplaincy services in hospitals due to fear of “creating a demand that can’t be filled by workforce”.
8) Maternal Mortality is increasing in the US and got a lot of attention especially related to future development of prenatal care standards. This also coincided with NICU and prenatal discussions.
9) The JC is just now starting to write standards for Children’s Hospitals. Input desired
10) The JC plans on writing standards for Long Term Acute Care Hospitals (LTACH) in 2011 which are an important population of patients for HPM.
11) The JC was embracing CMS COP’s for Telemedicine but CMS has momentarily stopped any work in this area and the JC does not know what will happen but reinforced their position that it is important for the future.
12) Health Information Technology is a complex integration program for the next few years. On example given is SNOMED-CT has no eMeasure code for “hospice care” in the comfort care section.

Overall, the meeting was very productive and interactive. The JC continues to emphasize their desire to collaborate with other organizations. With a growing number of competitive enterprises like the JC, we should expect more outreach, dialogue, and ability to contribute to their activities.

Chassin MR, Loeb JM, Schmaltz SP, Wachter RM, “Accountability Measures- Using Measurement to Provide Quality Improvement”, NEJM, June 29, 2010.

When Patients Are Overtreated

Have you seen patients who are overtreated? If so, you are not alone.

A list of medical care services that are overused was compiled by the National Priorities Partnership, which is convened by the National Quality Forum. Non-palliative services at the end of life is included in the list. In addition, specific tests and surgeries are noted such as x-rays, cardiac CT scans, heart bypass surgery, back surgery, knee and hip replacement, prostatectomy, angioplasty and hysterectomy. To learn more, go to

What exactly is overuse? The Institute of Medicine defines overuse as when the potential for harm of a health care service exceeds the possible benefit.

Palliative care clinicians have been quiet observers of overuse. Dr. David Weissman, professor emeritus at the Medical College of Wisconsin, says, “The continued use of chemotherapy by my peers, as the end-of-life approached, was one of the reasons that drew me to the new field of palliative medicine in the late 1980s.”

Patients are speaking up. This month, Consumer Union’s Safe Patient Project launched a “Share Your Story” survey of patient experience of overtreatment across the lifespan. Go to and click on “Share Your Story”. What do you think about patients sharing their stories of overtreatment?

Palliative care enables patients to receive the care they need, no more and no less. That’s why the National Priorities Partnership included palliative care and end-of-life care as one of its six national priorities.

As a health care professional, if you have seen patients overtreated, what do you do? How do you ensure patients receive only the care that will benefit them?

The writer is the author of The Treatment Trap (March 2010) and was chief architect of the Robert Wood Johnson Foundation’s palliative care strategy.

Inside the Process of Authoring a Book: Diane Meier on Palliative Care: Transforming the Care of Serious Illness

Our recent book, Palliative Care: Transforming the Care of Serious Illness (Jossey-Bass, San Francisco 2010), has been a long time coming. I got the invitation from my co-editors Stephen Isaacs and Bob Hughes of the Robert Wood Johnson Foundation over three years ago. The book was to be another in an annual series of books on health reform in areas of significant investment by the Foundation. Prior volumes addressed the Campaign for Tobacco Free Kids and School-Based Clinics, among others. I was asked to both write an introductory essay placing the field in context, and to help select a series of previously published articles for reprinting in the volume. The audience for the book was a matter of some discussion- we settled on the educated public and, we hoped, health care policy makers. The reprints were to serve as the signal and seminal pieces that exemplified the evolution of the field from its inception to its current status.

Sounded simple enough.

Many, many, hours and three years later, we had a draft ready to go press. The articles were chosen with a great deal of input from colleagues in the U.S. and around the world and lots of great pieces of writing had to be left out for lack of space. My essay started with the roadside hospices for the Crusaders of medieval times and ended before the passage of the 2010 Accountable Care Act and I learned way more than I anticipated about the threads that contributed to our field now- the 14th century origins in church-sponsored hospitals for the poor and hopelessly ill; the evolution of the place of death from a familiar experience to a mistake in the “medical model” of the modern world; the new science of pain and pain management in the 1970’s; the revolutionary and determined roles of three middle aged women (British nurse, social worker and physician Cicely Saunders, Dean of Yale University School of Nursing, and University of Chicago physician Elisabeth Kubler Ross) in a male dominated medical business culture; and the power of a federal payment mechanism (the Medicare Hospice Benefit) as a mediator of social change. The development of the field of palliative care as an approach to the human experience of illness and disability stands on the shoulders of at least a thousand years of social evolution. Humbling. It helps to understand what came before in order to think about what should happen next. Some people want to use the book in colleges and universities and Schools of Public Health. Hope for the future.