Palliative Care

Hospitals, Hospice and SNFs. The Big Deceit

"We Need Creative Solutions" When I read or hear the sentence above, I think of one thing and one thing only. The solution is long in coming, involves input from multiple parties, has no obvious fix, is costly--in either money or time, and we undergird it by a whopper of a collective action problem. How about getting to the actual point: "The problem we are trying to solve has no answer. We likely know the best course, and it's staring us in the face. We can spend the next few days, weeks, or months pretending we are unaware of it or we can take half a loaf now and get back to work." The above ran through my mind as I read a new hospital transitions study out in Annals of Internal Medicine. The findings were not unexpected, by me at least, but the response by those who do not…

If I Were You, I Would Not Be Bullish on Long-Term Care

Last week I was in Dunkin' Donuts and noticed something odd—although the oddness did not strike me immediately.  The woman who was serving me could have been my grandmother. Ditto that when I was at Home Depot in the lighting aisle yesterday.  And ditto it again in Walmart this morning. I would never dream of seeing that as a kid. Ever. (more…)

95% of Inpatient Providers Would Get an F On This Exam

You all think you know hospice. You don't, and I will tell you why. Hospice is a bastard child of the Medicare system. It went live in 1983 as a standalone entity during the Reagan administration and remains a disjointed program today. I would characterize its evolution as such: the road to hell is paved with good intentions. Why is that? When you go into hospice, your care path goes 180, and usual Medicare rules don't apply.  The benefit reroute sometimes makes life harder for families and patients.  It's like handing your keys off into the hospice kingdom--they run the show, and it's both a blessing and a curse. (more…)

Wrongful Life

There have been recent discussions in the lay media about a growing trend of litigation cases focused not on the “right to live”, but rather on the “right to die”. These cases have involved patients who received aggressive treatment, despite having documentation of their wishes not to receive such aggressive treatment. Although unsettling, it is not surprising that this issue has arisen, given the national conversations about the exorbitant cost of care at the end of life in the U.S., and the frequency with which patients do not receive end of life care that is concordant with their wishes. These conversations have spurned providers and patients to discuss and document their wishes, via advanced care directives and/or POLST orders (Physicians Orders for Life Sustaining Treatment). There is now even a national day devoted to advanced care decision making (National Healthcare Decisions Day). While these documents are increasingly available for hospitalists…

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…)