Palliative Care

Getting Permission to Die

by Rachel Deming
by Rachel Deming When I first met Ms. G. she told me she was in such pain that she wanted to die. She had a nice life, a full life, and her pain was just unbearable, she told me. "I have to stay strong for my children, however," she said. "They want to see me, so I have to keep fighting, keep bearing this pain for them." Over the next week, I saw Ms. G. many more times. Sometimes she was in good spirits, and other times she would cry in pain, pleading to make it stop. One afternoon when she was feeling better, she asked if she could tell me her story. She told me that she had a great story, a story that was worth sharing. She grew up in the Philippines; as a young woman she worked at the U.S. air force base as a cleaner. While…
Rachel Deming is a fourth year medical student at University of California, San Francisco School of Medicine. She has a B.A. in Human Biology from Stanford University. Before applying to medical school, she taught high school science in Oakland, CA. Rachel is currently applying for pediatric residency programs  for next year, and has a special interest in palliative care, as well as medical education.

CMS Just Paid for Advance Care Planning. But You’ll Still Make More Giving Injections.

I know the following may convey a lack of gratitude.  CMS funds a code, and by doing so, validates an activity for so long many in medicine have overlooked or dismissed.  Many specialists probably viewed end of life counseling as "stuff" those docs in the offices without the cherry finished cabinets dealt with.  You know. Trivial stuff.  Well, at least we can put that little contrivance to bed.  Amen. Cash is hard to come by these days and introducing a newly funded service risks cost overruns from overuse.  But if I had to guess how often practitioners will utilize these new E/Ms (99497 and 99498), my bet would be less than expected--and CMS can ease their fears that providers will back their Brink's truck in. (more…)

Hey Hospitalists, Let’s Have a Conversation about “The Conversation”

by Howard Epstein, MD, FHM Last week, the Center for Medicare and Medicaid Services (CMS) - the nation’s largest payer of healthcare services and the 800 pound gorilla in setting medical necessity and coverage policies - announced a proposal to begin paying for goals of care and advance care planning (ACP) discussions between medical providers and patients. Sound familiar? It should. This is the same, seemingly no-brainer proposal that in 2009 was stricken from the eventually approved Patient Protection and Affordable Care Act (PPACA, AKA the ACA, AKA “Obamacare”) in response to the intentional and patently false accusations of government run “death panels” in the hopes of salvaging some measure of bipartisan support. As we all know, the bill eventually passed the following year without a single Republican voting in favor in either the House or Senate – and without funding for ACP sessions! This is not the first attempt…

The War That No One Wins

My uncle just died.  He was my mother's brother,  an irascible blowhard, a mercurial bit of a family dictator with a soft spot for small children. He had the unfortunately common clinical course of catastrophic illness followed by steadfast decline into the heartbreaking oblivion of dementia. This dementia was of a steep descent and his daily life was reduced to a nursing home, albeit one where my mother and his wife visited multiple times a day and advocated fiercly for adequate care. On Sunday he suddenly vomited, was noted to be febrile and tachypneic. He was, sensibly enough, a DNR with a "no transfer" to hospital order on the chart-though not in hospice care. His oxygen saturations fell to critical levels despite aggressive supplemental oxygen, and he began to struggle for breath. His breathing was noisy, and he developed tremendous secretions which he was unable to clear. My mother, at…

Passion to Improve Pain Care

by Dr. Solomon Liao Students and residents often ask me why I like my job so much and why I always walk around with a smile on my face when I’m on service. I respond that helping to relieve people’s pain is very rewarding. It provides instant gratification. The more challenging the case is, the more rewarding the result. Very few interventions in medicine provide as immediate an impact on patient’s function and quality of life as reducing their pain. The volume of pain patients is huge. Over 116 million Americans have chronic pain. As my father taught me, “You go where the need is.” However, as I learned from one of my college mentors, “The need is part of the calling, but the need is not the calling itself.” As a palliative medicine hospitalist, I provide pain management as part of a larger calling of symptom relief and whole…