Monday, June 29, 2009

Palliative Care Grand Rounds Vol 1, Issue 6

Welcome to the sixth edition of Palliative Care Grand Rounds, a monthly (appearing the first Wednesday of each month) summary of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.


Health reform has been at or near the top of the news this past month, so it's hardly surprising that health reform and palliative care has found its way into the blogosphere. Usually within the context of rationing and futile care.

The blog Practical Bioethics addresses this issue in a well-reasoned way on a regular basis. In one of last month's posts, Dr. John Landos comments on one particularly useful way to think of the debates about rationing. Nearly 30 years ago, early in my career as a health care executive, one of the must-read publications for us was an insightful piece on rationing by the noted health economist Uwe Reinhardt. The title is as clever as it is fitting: Table Manners at the Health Care Feast.

What should a doctor recommend for a 90 year old man with pancreatic cancer and liver metastases? Palliative care? An Ohio surgeon thought so. Read the experience of Buckeye Surgeon in his blog . KevinMD picks up on this notion of futile care in his post.

Maggie Mahar offers an edifying piece around who should be responsible for defining futile care. In this post, she presents the case that " we also need to “pay more” for certain vital services such as primary care, chronic disease management, and palliative care. "

Are financial incentives for providers properly aligned with good palliative care? A New England Journal of Medicine article offers up a report on this matter, and Drew Rosielle, MD captures its highlights in his post. In a similar vein, Pallimed picks up on the hospice cap issue, as well as a recent press release from the National Alliance for Hospice Access. Access to the hospice benefit is a vital issue for patients, clinicians, executives, and policymakers, and has stirred up conflicting position statements and controversial points of view. To this blogger, the key question has been submerged. How should health care providers best organize to better assure open access for those with advanced illness, is what we ought to figure out.

Rationing versus futile care. Reading the blogosphere, and particularly comments to postings, leaves one with the impression that advanced illness management is either one or the other.

Prompted by President Obama's interview reply on the subject of the American approach to the end of life, David Tribble, MD, blogs about the "absurdity" of spending scarce resources on therapies known to be ineffective, but which Dr. Tribble adds, "we employ simply because we cannot stand not to."


Alex Smith, MD, posts in the blog Geripal of the challenges of incorporating geriatric and palliative care into the Emergency Department. Dr. Smith asks "How can we integrate the vast experience and strengths of palliative and geriatric medicine in a setting such as the emergency department to meet the needs of older adults with serious illness, and contain costs?" No easy answers, to be sure, but a question every ED director and hospital executive should be asking. We know the HPM MDs and geriatricians have been asking questions like this for the past 15 years.

In his Medical Futility blog, Thaddeus Mason Pope comments on the disappointing, but unsurprising, survey results that Advance Directives are followed SOME of the time. Should we be doing more to make POLST documents a national standard?


For patients and families seeking answers about palliative care, there are a handful of worthy blogs. In one, Dr. Pedro Calves relates an encounter with a patient who found the "pal" in palliative care. In another, written from the perspective of a patient under the care of hospice, the blogger/hospice patient comments on her health plan's reversal of an earlier denial and her change of hospice providers. When the author first started this blog, it was mainly to keep the people in her life up to date on how she was doing; now, it seems that she has picked up readers outside her immediate circle of family and friends. Angela Morrow brought this blog to my attention in last month's Palliative Care Grand Rounds.

Dr. Drew Roselle posts that most patients with advanced illnesses prefer to have hospice discussions, yet a recently published study found that only half of patients in this study had such discussions, and in a separate yet related post that understanding of CPR outcomes and code status is poor among hospitalized patients.


Mort Kondracke is the Executive Editor of Roll Call, the newspaper of Capitol Hill. While technically not a blog (it's actually a column), Mr. Kondracke pays tribute to his mother's example of living - and also a "public policy" tribute to the manner of her death, in HOSPICE care. As health reform moves through Congress, a voice like that of Mr. Kondracke can be very powerful.

Veteran journalist Larry Beresford, who has written extensively about palliative care, discusses the emotional barriers to hospice access for people with terminal illnesses in a thought-provoking piece . Referring to several recent research studies, Mr. Beresford notes that
"this kind of research can help us understand some of the nuances of such encounters at the end of life, but I wonder if they take us closer to solving hospice's Flying Dutchman status in our society."


Jessica Knapp writes in her blog The Good Death that she gives a two thumbs-up to the film, Departures, which, without much fanfare, won this year's Academy Award for Best Foreign Film. Then again, how many foreign films (award-winning and not) are greeted with great fanfare?
Glad that Ms. Knapp brought it to our readers' attention.

For a peek into the week of a hospice nurse, see Dethmama Chronicles. And Pallimed directs us to a week in the life of a palliative consult service, via Twitter.

Christian Sinclair, MD, co-editor of Pallimed and one of the prime movers behind Palliative Care Grand Rounds, announced a social media marketing venture and a sabattical from Pallimed. But not before he posted a useful summary of legislative and regulatory issues concerning palliative care.

On the arts/technology side, Amy Clarkson, MD reports on the complimentary blog of Pallimed about The Digital Afterlife, the legacy lockers and digital memorials brought to us by digital technology.


Thanks to all who sent me suggestions for this month's Grand Rounds! And if you're interested, here's where you can find issues 1 , 2, 3, 4, and 5.

PCGR now 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.

Next PCGR will be out August 5 and will be hosted by Risa Denenberg forward suggestions or links to .

Friday, June 26, 2009

Palliative Care Blog Wrap-Up

I'll be hosting next month's Palliative Care Grand Rounds. Sign up here for a feed... and you'll have next month's, and the ones following, delivered to your desktop.

Monday, June 22, 2009

Advanced Palliative Care Communities (APCCs) - What Distinguishes Them?

What is it about Advanced Palliative Care Communities (APCCs) read here that distinguishes them from other communities (or regions) when it comes to providing care to those with end-stage disease? One is the presence of an organized provider network collaborating on the delivery of palliative care in many settings of care throughout the community. Another is the documentation of, and adherence to, patient preferences. Think POLST or similar tools. Surely, these attributes do not come about on their own. We’ve looked more closely at the deployment of palliative medicine specialists in these communities (APCCs) and have found greater numbers (than in other similar communities) of physicians practicing palliative medicine and greater use of those physicians in clinical consultative roles in multiple settings throughout the community. What does not matter, we've found, is the organizational sponsor (or employer) of these palliative medicine physicians.

Wednesday, June 3, 2009

Palliative Care Grand Rounds 1.5

The latest edition of Palliative Care Grand Rounds is up today on Angela Morrow's blog. Excellent summary of last month's most interesting posts about palliative care and related topics. For issues 1-4, visit the Grand Rounds Blog.

I will be hosting July's Grand Rounds (July 1) - send your suggestions to

Tuesday, June 2, 2009

Physician Services at the End-of-Life - Are We Now Ready for REDEPLOYMENT?

Los Angeles, California; Manhattan, New York; and New Brunswick, New Jersey, had very high physician labor inputs for both Academic Medical Centers' (AMCs) end-of-life cohorts and the region’s Medicare population. Minneapolis and Rochester, Minnesota (home of the Mayo Clinic), had low regional and AMC physician labor effort. This correlation suggests that the variation observed across regions cannot be explained by differences in health status, adequacy of care, or patients’ preferences but is linked to idiosyncratic patterns of labor input found in both AMCs and their associated regions. So concludes a 2006 study "End-Of-Life Care At Academic Medical Centers: Implications For Future Workforce Requirements", David C. Goodman, Thérèse A. Stukel, Chiang-hua Chang and John E. Wennberg.
[Health Affairs 25, no. 2(2006): 521–531; 10.1377/hlthaff.25.2.521]

The authors also observe that in several of the low-input regions, much of the care is provided by large, multispecialty group practices (for example, the Mayo Clinic) or integrated delivery systems (for example, Intermountain Health Care). What is it about such practices and delivery systems that lower the barriers to palliative care, in fact, may encourage more appropriate use of palliative care for those with advanced AND chronic illness? Just a hunch, but I'd surmise that a key element is a shared or common compensation system among palliative medicine physicians, primary care physicians, and specialists. What might support the design of new compensation systems to promote the sort of physician collaboration essential to this redeployment? The likely prospect of payment bundling , a payment reform which has been advocated as a means of reducing readmissions.
Surely there must be other factors besides compensation incentives at play. I'm curious to learn what other possibilities come to your mind?

End-of-Life Care and Physicians: Shortage or Surplus?

If fewer physicians are needed to care for the growing numbers of seniors, as this article concludes, then how will physician services be redeployed? In favor of palliative medicine physicians, to be sure. Yet, other specialists can not so readily be expected to relinquish their current roles in end-of-life care. Or, is there plenty of room for many "specialists", each applying their own competencies in close coordination with their medical and nursing colleagues. I'm curious to learn your views on the surplus/shortage issue (especially as it relates to end-of-life care) and suggestions on how to best hasten the redeployment of physician services so that it is factored into health reform.

Choosing Where to Live Based Upon End-of-Life Preferences

A health executive new to hospice asked the other day, in advance of assuming an executive role of a palliative care organization in a resort community, what role should physicians play in the end-of-life care in the community? I replied a small one (relative to the role that specialists were presently serving). But a larger one for palliative medicine physicians. He asked why that wasn't the case at present. Because patients don't choose their regions they live in based on the amount of care they wish to receive in their last six months of life, I replied.
I wonder, will there be a day when those choices are made?