End of Life Care

How Often Do You Ask This (Ineffective) Question?

How often do we get complacent with knowledge?  We hear the same thing over and over, and the message becomes lore.  Drink eight ounces of water per day or turkey makes you drowsy—not only do we as docs believe it but we tell family members and patients the same. I came across a new study in CMAJ that fractures another piece of lore we hold fast. And not only should this study put the kibosh on it, but also upends a practice (a patient question) that teachers from eons past have instructed us to use over and over and over.  The question has intuitive appeal, is easy to gestalt, and has a universal understanding.  Non-physicians and laypeople can grasp what the answer implies without any difficulty.  (more…)

The Best Way to Die?

by David Brabeck, MD, FACP
By David Brabeck, MD, FACP Medicine can be a strange business. Trainees are often thrust into situations involving life and death in which there is often little formal education for end of life experiences. Moreover, relatively few have personally experienced family members or loved ones dying. The population of the United States is aging and palliative care is a growing field. Despite this, formal medical school education regarding palliative care and hospice is quite varied and often inadequate. A recent review in the journal Medical Education reported that medical schools’ curriculums include between two hours and several weeks of training for end-of-life issues. With limited training in this area, residents and supervising attendings are often left to experiential education to guide them in their communication and medical decision making when a patient is close to dying. These can be difficult waters to navigate when futility of care and patient’s wishes…
David Brabeck, MD, FACP is Associate Program Director, Internal Medicine Residency, in the Departments of Hospital Medicine/General Internal Medicine at Lahey Hospital and Medical Center in Burlington, MA. He can be reached at david.m.brabeck@lahey.org.

Male Versus Female Hospitalists

If you have paid attention to the news, you picked up the study out in JAMA concerning how male versus female physicians deliver inpatient care.  Not just any inpatient docs, though, but hospitalists. The investigators were meticulous in their analysis of over a million Medicare beneficiaries and looked at readmit and mortality rates.  They examined various diagnoses and adjusted for the usual doctor and hospital characteristics. Across the board, males took a drubbing and the NNT for both outcomes of interest hovered around 200 (0.5% absolute difference). Ashish Jha, one of the investigators and a leader in the study of hospital quality and safety (who really needs to speak at an SHM annual, incidentally) goes into more depth over at his blog: (more…)

Legacy from the Dying to the Living

by Jamie Yao
By: Jamie Yao Jamie is a fourth year medical student at the University of California, San Francisco entering into the field of internal medicine. She shares how her recent experience on a palliative care rotation at Moffitt Hospital in San Francisco, CA inspired her to express her feelings through poetry. Many of the moments on my palliative care rotation, such as the ones described in the poem, were inspiring. One that particularly resonates is when I had the opportunity to facilitate and witness the video chat exchange between one of our patients and his family, including his young children. It was simultaneously joyful and heartbreaking to see the love shared between him, his fiancee, and children. It was one of the many examples I encountered of the interactions between patients and their loved ones, who were often the crux of what patients derived meaning from in their lives. "Legacy from…
Jamie Yao is a fourth year UCSF medical student entering the field of internal medicine. Prior to medical school, she majored in Microbiology, Immunology, and Molecular Genetics at UCLA and completed a year of AmeriCorps with Hudson River HealthCare in Peekskill, New York. During her time on a palliative care elective at Moffitt Cancer Center, she had the privilege of working with and learning from an interprofessional team that showed her the varied ways that providers can care for patients. After being incredibly impacted by the patients she met and the vulnerability, resilience and love that they shared with her and their loved ones, she wrote her reflections in the poem, "Legacy from the Dying to the Living."

The Last Days: Cash or Credit?

How often do you hear the following: the average senior utilizes  25% of their lifetime health spend during their last six months of life.  Too much. All that service use in such a concentrated period suggests possibilities. ICUs and inpatient care have great costs.  Our acute and post-acute institutions also do not hold up as models of efficient care delivery.  Most of them at least. What to do? I see the above observations as something akin to an emperor with no clothes. Because leaders with checkbooks have a focus on areas that will generate cost reductions, they seek opportunities they can wrap their arms around.  The more disadvantaged and disjointed ambulatory practices cause too many headaches.  Hospitals then seem like the right place.  Hospitalists and inpatient practitioners seem like the right people. The logic goes, with advanced directives and creative thinking, the right docs and facilities can make a dent…