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 .


PallMDHouston said...

As someone who has been working in the palliative care field for only several months, I'm happy to see so much interesting information in these blogs. I plan to subscribe to this blog and to Palliative Care Ground Rounds.

Gail Rae said...

I always love PCGR. I'm scurrying over to alert my readers (few as they are, at the moment) about this issue; then I'll be back to continue reading. Thank you, Mr. Cousounis!

Risa Denenberg said...

Thanks Tim, you gave us a cohesive story, insightful comments, plus some new bloggers. Great work!

Jessica Knapp said...

Awesome job! I love that you sourced Roll Call. It's always so inspiring to read these. They remind me how much more room there is to be creative as a blogger.

Christian Sinclair said...

Thanks again Tim for offering to do this. Hope you had a good time looking through all the offerings! And thanks for mentioning Pallimed!

I am glad to see a new blog I had not heard of Geripal. Looks like they will be a nice new addition to our circle.


I appreciate the feedback - putting together Grand Rounds was enlightening and enjoyable.
I'm encouraged by the attention focused on palliative care by clinicians, policymakers, and the general public. let's sharpen that focus!

Alex Smith said...

Thank you for your fantastic summary. And so exciting that you mentioned our nascent blog,! We're brand new to the blogosphere, and any advice you can give to us on how to improve our site would be greatly appreciated. We see ourselves as a site for discussion, fermentation of ideas, and freethinking commentary by clinicians interested in geriatrics and palliative care.

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