There I was in ICU rounds (the Palliative Care Team attends ICU rounds) shaking my head as usual. One of my nurse practioner students told me she disliked going to ICU rounds because it was like a “Nursing Home.” She was saddened to see so many geriatric patients, in the ICU, mostly with a poor overall prognosis. The words “Trach and Peg,” ran through my mind for hours after rounds because so many patients were being “Trached and Pegged.” Those words brought so many negative emotions and feelings; sadness, fear, isolation, pain and suffering to name a few. The words and images burned into my mind, that for the rest of the day it was like a song that haunted me…”Trach and Peg, Trach and Peg.” The words bothered me to the point that I had to write the following:
“Trach and PEG”
“Trach and PEG”
Those words sound horrible in my ears.
Unknowing to families an artificial prison for months or years.
The family will never know what to expect.
Bedsores, UTI’s, pneumonias, you name it, continue to occur even without neglect.
Most families doing the best they can,
thinking that this is the best plan.
While I make rounds in the ICU
will the patient suffer through another code blue?
“Trach and PEG”
“Trach and PEG”
Posted in Geriatrics, ICU, Palliative Care, Uncategorized | Tagged End-of-Life, Geriatrics, ICU, Palliative Care | 10 Comments »
It seems like just yesterday I posted my last blog entry, but it was over 18 months ago. It’s true the older you get the faster time flies. I’m sure people have wondered what happened to me (not that I’m that popular ), but life has happened to me. I have so many ideas for blog entries but never get around to writing them. I think I have a false expectation for myself. I guess with great blogs like Pallimed and Geripal out there it makes me feel like writing long thoughtful entries are the way to go. I’m going to try and write short but hopefully powerful entries. If you have continued to follow this blog, thank you, it has a special place in my heart.
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I’m a little late in posting this but the Palliative Care Grand Rounds is hosted by Larry Beresford; see link below. Palliative Care Grand Rounds (PCGR) is hosted by different bloggers every month. The goal of PCGR is to summarize the blogs that the blogger feels are related to Hospice and Palliative Medicine and most likely would be interesting for all those in the Hospice and Palliative Medicine blogosphere. PCGR is published at the beginning of each month and I will post a link every month. Please enjoy PCGR while you take a tour of the awesome array of blogs related to our field.
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Leaving a conference like this is always bitter-sweet. Sweet because I miss my family and can’t wait to see them. Bitter because I’m leaving behind mentors, colleagues, old friends and new friends. It’s nice to be amongst a group of people who are very like-minded but still very unique. I didn’t appreciate this fact until I had a conversation with a medical student today and realized how diverse and unique our clinicians are compared to other specialties. Of course, we are the only specialty that has so many different paths (multiple specialties) to the same goal (Hospice and Palliative Medicine Board Certification). Also, the number of Social Workers, Chaplains, Nurses, Nurse Practitioners, PA’s and other Allied Health Professionals that come to this meeting further make it special in by bringing their unique training and experiences to the table. What other conference would have such a diverse population of health care providers. I smile to think what a Cardiology or Orthopedic Conference would look like with the above health care providers in attendance. Did I mention that I love my specialty and the amazing people who make it what it is. It was inspiring to hear the different stories my colleagues told me…moments at the bedside of a dying patient, being present for a suffering family, palliating severe pain, counseling patients about goals of care, praying with patients and families, managing symptoms of cancer patients and the list goes on and on. During the daily in’s and out’s of patient care one can easily lose sight of the big picture. We are always on the verge of compassion fatigue, but yet its brief moments in time like this that I cherish. A gathering of people who are…yes, like-minded and unique and inspire me with their stories and their heart to continue to do what I do.
Goodbye Boston, Good bye friends…until next year!
Vancouver is only 11 months away!
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Today is officially day 2 of the conference (this is day 3 for me as I participated in some of the preconference workshops). I appreciated another great day today. In addition to the great speakers and networking with new people, I was able to catch up with old friends and colleagues. For this reason I am sad I was unable to attend the Pallimed/Geri-pal meet and greet. Maybe next year! Listed below are several take home messages I learned today.
1. “Caring for the Patient with ALS: It Takes a Village.” I have taken care of ALS patients and even though I haven’t been practicing long, I’ve probably seen more ALS patients in hospice than most primary care physicians in practice. This is most likely due to the prolonged relationships that patients develop with their primary team of Neurologists and other providers much like cancer patients become very attached and involved with their oncologist and their staff. There was a nice overview of ALS and how a certain hospice program has made ALS a focal point in their care. As they have learned more about ALS, educated their staff and worked within the VA system they have seen their referrals increase. They encouraged hospices to be more involved and if possible work in partnership with the VA system to take care of this unique population. They pointed us to a great website for resources and further information. The ALS Association; http://www.alsa.org.
2. Gail Sheehy, Guest Speaker and author of “Passages in Caregiving: Turning Choas into Confidence.” She talked about her journey with her husband as he battled cancer, over a prolonged period of time, prior to his death. Her story was touching as she told it and explained the role of palliative care in the impact of care not only for her husband but also for herself. She also agreed that many people don’t know what palliative care is, and think that palliative care = hospice (I cringe every time a physician talks about palliative care in regards to End-of-Life Care).
3. Paper Session.
a. There is an increased need for Outpatient Spiritual Care as this paper shows that patients receiving Outpatient Palliative Care want Spiritual Care to be part of their medical care.
b. The significant majority of Outpatient Palliative Care programs are associated with an Inpatient Palliative Care programs. What surprised me is that most Palliative Care programs are associated with smaller hospitals and most are tied to Non-for-Profit Hospitals.
4. “Physician Compensation Models.” Very unique discussion. Still many unanswered questions about how to fairly reimburse physicians in hospice and palliative care. It mostly breaks down into two models, Salaried versus Incentive based. What was unexpected to see, and caught me by surprise, was the number of physicians being salaried by their respective hospices. Also, many more hospices are beginning to employ physicians Full-Time versus part time or as independent contractors. Both types of reimbursements have advantages and disadvantages; however, an argument could be made that a hybrid model may be able to make both parties happy and minimize the disadvantages. This model would include a lower based salary with benefits but a percentage of the physicians compensation would be incentive based. By this, they would be reimbursed a portion of their income based on the number of patients seen per week or month or however it is worked out. There will be much information to follow in the future months and years as more physicians converse about this topic.
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Today at the AAHPM Assembly I attended four educational sessions. The one that made the biggest impact on me was the presentation entitled “None of Your Darn Business! Taking a Spritual History While Preserving Your Professional Boundaries, Your Rapport, and Your Pride,” by Tim Ford, MA MS CT at VCU Massey Cancer Center, Richmond, VA. Before I talk a little bit more about this, I also wanted to list the other educational sessions and what I took from them.
1. “Is it Futile to Discuss Futility? A review of the Medical Literature and Legal Precedent.” Futility is a difficult word to define and means many things to different clinicians. Many advocate because it is so politically charged that we get rid of it. One physician suggested that Futility is the other “F” word. Basically, there is much evidence from previous cases and court rulings that physicians are hardly ever successfully sued for a wrongful death when non-beneficial life sustaining treatments are withdrawn. I contended that many physicians do not want to withdraw care when a family “wants everything done,” due to the fear of litigation. Many physicians would rather practice against their better judgement and subject patients to things they disagree with because this is “what the family wants,” and they do not want to anger the family or make them feel that they are not appropriately taking care of the patient. It’s much easier to continue to “do” things to the patient than to discuss this with the family in an open and honest way. Nadia Tremonti, MD, Wayne State University and Children’s Hospital of Michigan made a good point about this. She stated that as physicians we have a certain obligation to the patient and the profession despite the fear of litigation. We understand as physicians that we have a certain responsibility to the patient and by choosing the easy way out we compromise ourselves and the integrity of medicine. Overall, a great presentation and much discussion afterward.
2. Paper Sessions. I attended the paper sessions covering the Palliative Care in the ICU. The take home message from all three papers is that Palliative Care can be beneficial to patients in the ICU setting. Some crossover points in all three papers are the following. Palliative Care in the ICU:
a. Showed a decreased length of stay in the ICU
b. Increased DNR’s
c. Decreased utilization of more “aggressive” measures
d. Improved relationships between the ICU staff and the Palliative Care team
e. Increased support for the ICU staff by the Palliative Care team
f. Improved physician understanding of the role of Palliative Care in the ICU and increased utilization
g. Increased cost avoidance for the hospital showing that Palliative Care programs are beneficial, self sustaining and enforce the “Mission” of most hospitals
h. Improved patient and family satisfaction scores
i. Other…(mostly stuff I forgot)
3. “Hospice and Nonhospice Models of Palliative Care Delivery.” The bit of information that stood out to me in this session, is that some SNF’s (Skilled Nursing Facilities) are beginning to implement a “Home Grown,” palliative care service on site. Advantages and disadvantages were discussed for this type of model and I had never really thought of this as an option. I heard of the other two models in which outside Palliative Care consultants are called in to do consults or a local hospice providing non-hospice palliative care to nursing home patients, but I was not aware of the “Home Grown” model. Lots of good discussion and it will be very interesting to see how this unfolds in the coming years.
4. Last but not least, “None of Your Darn Business! Taking a Spritual History While Preserving Your Professional Boundaries, Your Rapport, and Your Pride.” This session impacted me the most because as a fellowship trained Palliative Care Physician I had always advocated for spiritual care as an important piece of patient care, but never truly appreciated the spiritual care component until this presentation. I felt like my eyes were opened and I had a deeper understanding of spirituality in palliative care. How can one presentation make such an impact. Well, he presented several points that I had not considered and he also introduced the “Transdisciplinary” (TD) approach to palliative care rather than the more traditional “Interdisciplinary” (ID) approach. In the traditional ID approach each member of the team evaluates the patient within their “nich” of practice and shares that information with the team. By contrast, the TD approach has each member providing care in all 4 domains (physical, psychological, social and spiritual) as a “generalist” but provides “specialist” care in their area of expertise. For example, in the process of doing a full consultation with a patient, I may sit down and listen to their story (presence, connection) and learn what provides “meaning” in their life while obtaining the history of the patient. In fact Tim Ford advocates that much of the spiritual history can be taken from the patient just by listening to their story and in the process of doing the consultation without having go through a checklist. In this way I am a “generalist,” for the “specialist” (chaplain) to follow up after this information is shared with the chaplain. In the same manner he stated that he would not ignore soiled linens if he went to see a patient or ignore their excruciating pain. In fact he stated that he may not be able to address their spiritual pain if the physical pain is not adequately addressed. I have often seen this on my hospice team. I will get an occasional phone call from the chaplain stating a patient he was visiting was having increased pain. He has been trained in basic pain management to a level that he can relay pertinent information that I will use for appropriate follow up care. In this manner he is being the “generalist” and I followup as the “specialist.” I feel that this model engenders the true definition of holistic medicine. And lastly he reinforced the power of “presence.” The power of “just being” present can make a significant impact on a patient or family. I am thankful I attended this session and will take a new found interest and zeal back to my practice in regards to spiritual care.
Posted in Hospice and Palliative Care, ICU, Malpractice, Skille Nursing Facility, Spirituality | 4 Comments »