tag:blogger.com,1999:blog-20352591.comments2022-03-15T05:51:40.074-04:00LIFE IN THE END ZONEMuriel Gillickhttp://www.blogger.com/profile/13001304171183760292noreply@blogger.comBlogger42125tag:blogger.com,1999:blog-20352591.post-1344645889358440872017-11-08T14:07:32.068-05:002017-11-08T14:07:32.068-05:00Midway through this book and finding that it accur...Midway through this book and finding that it accurately portrays the experience of care. It also explains the many forces at work that make it difficult to "fix" that experience: too many providers and vendors are focused on their own business plan, seeing patients as passive "units of revenue." Thanks for making a complicated problem easy to understand. Anonymoushttps://www.blogger.com/profile/08162056251735236969noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-68811945946367703832017-07-10T13:51:31.153-04:002017-07-10T13:51:31.153-04:00Once again, you are a true advocate for improving ...Once again, you are a true advocate for improving the resources available in the nursing home setting as one of the solutions to our upcoming "caregiver gap." One of the challenges with research is that the study of "education" = and as you point out, compliance with the educational component was rather sketchy" - is fraught with the potential to not understand the interdependencies with other, equally influential variables in a decision to stay in a NH or insist on transfer to a hospital.<br /><br />Would need to understand the level of trust that the resident/family has in the NH, the degree to which their are visible signs of enhanced care, i.e., medical staff onsite, sophisticated equipment that signal increased attention, etc. Hard to ask residents/families to take promises "on faith" when there is a history of bad press, negative reactions from their larger social circle, etc.Anonymoushttps://www.blogger.com/profile/08162056251735236969noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-71184551721245922962017-06-04T17:17:20.561-04:002017-06-04T17:17:20.561-04:00Unfortunately, this law was also passed in an era ...Unfortunately, this law was also passed in an era when most patients still expected their end-of-life process to be managed by their own primary care physician.<br /><br />Nowadays some patients still assume that will happen, but anyone hospitalized in a critical situation will be managed by hospitalists, intensivists, or residents. Many times those doctors won't know the name of the patient's primary care physician. Many times, even when they do know, they don't call to ask questions, much less 'consult.'<br /><br />I agree that the check-box form is utterly inadequate. We still have to do something to provide some continuity of care between the patient in good health (or declining health) and the same patient at the end of life.Maggienoreply@blogger.comtag:blogger.com,1999:blog-20352591.post-55668370797855945922017-05-17T15:06:49.420-04:002017-05-17T15:06:49.420-04:00Thanks for posting this. Your insight that, despi...Thanks for posting this. Your insight that, despite all the attention, the techniques, protocols and training still not getting to the heart of patient falls. I am not a clinician, but a family caregiver and for my money, the issue is that the equipment used to help patients with mobility and self-care for activities such as self-toileting DO NOT support FUNCTIONAL INDEPENDENCE or SELF-CARE. Rather than wait for staff to assist, many patients and families visiting will initiate unsafe activity using equipment with substandard design. I believe that a call for optimizing the functional/self-care level during an in-patient visit also spills over to the post-acute caregivng experience. Yet clinicians tend to be dismissive of equipment as an actionable input for treating their patients, perhaps because they see "for-profit" companies ready to take advantage in a manner similar to pharmaceutical companies. They would rather keep care planning within the frame of their own skill set rather than demand better equipment.Anonymoushttps://www.blogger.com/profile/08162056251735236969noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-30051217936431620402017-03-07T17:55:59.081-05:002017-03-07T17:55:59.081-05:00Dear Muriel,
I enjoyed reading "A Piece of M...Dear Muriel,<br /><br />I enjoyed reading "A Piece of My Mind." My blog on purchasing drugs from Canadian pharmacies, which I have long advocated, may be of interest to you. See<br />http://www.treeoflifehealthadvocates.com/category/prescription-medication/<br /><br />Kind regards,<br />Ruth Linden, Ph.D.Anonymoushttps://www.blogger.com/profile/07773664090927012979noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-22755476220604336622016-08-23T12:56:26.793-04:002016-08-23T12:56:26.793-04:00Is there any doubt that for-profit PACE programs w...Is there any doubt that for-profit PACE programs will be the same as for-profit nursing homes? Caring for the most frail and vulnerable older adults and profit motive will not mix well. We can make estimates on when the first exposes of poor quality care in for-profit PACE will be published.winzelbandhttps://www.blogger.com/profile/18328717510963860566noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-4574054437670601742016-01-06T12:47:52.735-05:002016-01-06T12:47:52.735-05:00One of the problems is that a single visit that cr...One of the problems is that a single visit that creates recommendations for the PCP too often ends up in a file somewhere, never seen by the patient (who often did not understand the purpose of the home assessment visit anyway, or was not interested in making changes but wanted to be cooperative with the request for a visit and lonely enough to enjoy any visitors who are willing to listen to them) or by the caregivers. <br />Even when the plan doesn't disappear, the question of who pays for these recommended services - emergency alerts, home care givers, medication prepackaging systems, wheelchair ramps, etc. - is not addressed. <br />In Massachusetts there are state funded resources for making this type of plan, and access to some funds to pay for them and ability to discuss with family (if ok with client) the rationale for each recommendation and where to purchase particular items or services. There is also a waiver program with Medicaid that allows a great deal of services (including RN oversight and ongoing care management with RNs and SWs) to help support frail elders living in the community. <br /><br />clairesmumnoreply@blogger.comtag:blogger.com,1999:blog-20352591.post-48166983128379441042015-11-03T13:59:59.052-05:002015-11-03T13:59:59.052-05:00Nice post Dr. Gillick!
I am under the impression ...Nice post Dr. Gillick!<br /><br />I am under the impression that to date, most Medicare HMOs have not very effectively coordinated care to improve outcomes and minimize hospitalizations. Any particular ideas as to why?Anonymoushttps://www.blogger.com/profile/06993344520035324713noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-64240074203644541532015-05-04T17:48:25.526-04:002015-05-04T17:48:25.526-04:00Perhaps we need to expand the concept of shared de...Perhaps we need to expand the concept of shared decision-making beyond just clinician and patient. In fact, the patient often consults multiple trusted advisors as part of their process of understanding, assessing risk, and crystalizing treatment preference. Having just recently gone through this process for myself, I have realized that making a decision is often the result of multiple inputs acquired over time. The information from my clinician is only one part of what I considered. Thus, the "capture into the EMR" that the clinician has to do to meet documentation requirements is just that, documentation. It does not get to the core of decision-making. To really support patient-centered care delivery and shared decision-making the physician must capture not only the "what I want " but also the "why I want" along with the inputs. <br /><br />I have a recent example where the standard treatment recommendation was medication therapy rather than surgery. My personal journey included talking to the clinician, the surgeon, a second opinion doctor, my sister who had had similar surgery, my brother who had had medication therapy and thinking about my lifestyle and personal goals. Only after all those inputs, was I able to decide that I was willing to risk surgery and to advocate to my clinicians a surgical approach.<br /><br />Shared decision-making for me included many more sources than just the physician and myself. Perhaps this is why even doctors abandon "shared decision-making" when confronted with personal health issues.GailEnoreply@blogger.comtag:blogger.com,1999:blog-20352591.post-87581072766348158122015-03-11T19:20:37.345-04:002015-03-11T19:20:37.345-04:00Nice article about a very important concept. I ag...Nice article about a very important concept. I agree that the similarities and differences between informed consent and shared decision making are too infrequently discussed.<br /><br />I want to take slight and gentle issue with the assumption that the clinician <b> must </b> make a recommendation. <br /><br />I see this as a spectrum. There are certainly time where it seems expected and even obligatory, but there are also times where I believe it is best that the clinician not make a recommendation until the patient has had a chance to make an uninfluenced decision or ask explicitly for a recommendation.<br /><br />pheskihttps://www.blogger.com/profile/16102200723940843059noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-42342938824861026752015-01-25T21:37:42.998-05:002015-01-25T21:37:42.998-05:00Great post! A patient who can "see and hear&...Great post! A patient who can "see and hear" her condition at hand, as well as options for treatment available, may be more likely to better absorb the information than through verbal communication. I, myself, would feel more empowered in my ability to discuss my treatment with my provider through this kind of exchange.<br /><br />kitscatcalhttps://www.blogger.com/profile/12733660074261319308noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-76727746392859260632014-12-29T11:59:25.252-05:002014-12-29T11:59:25.252-05:00Thank you Dr. Gillick for yet another thought-prov...Thank you Dr. Gillick for yet another thought-provoking post. <br /><br />Am particularly intrigued by your suggestion that assisted living facilities provide comprehensive assessments. This sounds useful -- for every older adult -- but hard to implement in real life, esp at scale. Who would do the assessments?Anonymoushttps://www.blogger.com/profile/06993344520035324713noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-23954074010150986202014-11-09T23:33:04.044-05:002014-11-09T23:33:04.044-05:00Oh, I quite agree. I chose dementia simply becaus...Oh, I quite agree. I chose dementia simply because it's such a glaring example of uselessly medicating folks. Many MDs are reluctant to even stop the dementia meds. SuesquatchRNhttps://www.blogger.com/profile/08430405540498968731noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-19647664180672369522014-11-09T21:01:55.138-05:002014-11-09T21:01:55.138-05:00You are right that many families do not understand...You are right that many families do not understand that dementia is a fatal illness and that advanced dementia is the final stage of the disease. My interest in this post was in pointing out that the need to consider limiting medications extends to many older patients, not those who are dying, whether of dementia or some other illness.Muriel Gillickhttps://www.blogger.com/profile/13001304171183760292noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-66695104120536323042014-11-09T15:04:54.735-05:002014-11-09T15:04:54.735-05:00One obstacle to lowering the number of medications...One obstacle to lowering the number of medications prescribed for those with dementia in particular is a misunderstanding on the part of families and, to a degree, physicians that dementia is a terminal illness. With the lack of a specific terminal event, such as those associated with CVA or CVD, the misunderstanding persists that dementia is not, in and of itself, terminal. SuesquatchRNhttps://www.blogger.com/profile/08430405540498968731noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-42990309440193190642014-09-15T10:27:10.239-04:002014-09-15T10:27:10.239-04:00Thanks for this interesting and informative post! ...Thanks for this interesting and informative post! I agree--I wouldn't want to have longevity without good overall health, and I'm sure there are many who would prefer to 'pass on' rather than continue to suffer. It should be easier to make that choice.<br />Nancy KaneAnonymousnoreply@blogger.comtag:blogger.com,1999:blog-20352591.post-34487005882358178652014-09-03T03:31:04.885-04:002014-09-03T03:31:04.885-04:00Hi Muriel,
Nicely done! I borrowed some of this h...Hi Muriel,<br /><br />Nicely done! I borrowed some of this here http://runningahospital.blogspot.co.uk/2014/09/alice-in-wonderland-had-nothing-on-this.htmlPaul Levyhttps://www.blogger.com/profile/17065446378970179507noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-27195597294025665942014-04-15T15:56:49.990-04:002014-04-15T15:56:49.990-04:00Dr. Gillick,
As always, you raise interesting and ...Dr. Gillick,<br />As always, you raise interesting and important points.<br /><br />Re whether we can afford primary care, the recently released 2012 Medicare spending data revealed that we spent $12 billion on outpatient visits, out of $600 billion. In other words, 2%. (Of which I'm sure most went to specialists, not PCPs.) <br /><br />Do you think there's any chance we can convince society to spend more on primary care?<br /><br />Re geriatric team care, it's a wonderful thing but seems to me it's usually not financially viable, outside the setting of PACE (which leverages Medicaid money because the states are trying to avoid nursing home placements). Many geriatric team practices are subsidized by academic medical centers, grants, or philanthropy.<br /><br />At some point, I hope you'll consider blogging about how we might make geriatric team care more financially feasible.<br /><br />Thanks for your blog, it's terrific. best, leslie kernisan<br />Anonymoushttps://www.blogger.com/profile/06993344520035324713noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-20184852918634507332014-03-24T12:52:07.530-04:002014-03-24T12:52:07.530-04:00This is a wonderful illustration of how tricky it ...This is a wonderful illustration of how tricky it is to care for people with dementia. Thanks for articulating multiple "frames" for the picture. jallyhttps://www.blogger.com/profile/01905731952829491945noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-16662801574058771552014-01-14T13:39:44.942-05:002014-01-14T13:39:44.942-05:00I appreciate the subjects you tackle in your blog,...I appreciate the subjects you tackle in your blog, Dr.Gillick. Having just left the work force and entered the Medicare system, the fact that it provides no dental coverage is concerning. Even more concerning to me, however, is the fact that Medicare, and private insurance for that matter, does not cover the cost of hearing aids. Hearing loss is disabling. Before I lost my group insurance, it paid for a new CPAP machine, yet neither it, nor Medicare, will pay for hearing aids. What's wrong with that picture?Anonymoushttps://www.blogger.com/profile/17076472649533258260noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-4462091443235790322013-12-16T16:04:48.469-05:002013-12-16T16:04:48.469-05:00Thank you for this important and relevant column. ...Thank you for this important and relevant column. My mother received excellent palliative care at the end of her life, when she decided not to continue the intensive treatment she was receiving. Her doc worked with her to find a way to withdraw active treatment and gracefully bow out of life. This is the same doc who recommended 'Five Wishes', a hugely helpful medical directive document she then used, and I have subsequently used and recommended to others (available online).Unknownhttps://www.blogger.com/profile/13758743552733470986noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-72131593401641118192013-10-24T20:39:07.676-04:002013-10-24T20:39:07.676-04:00I work as an ED nurse. There are often occasions ...I work as an ED nurse. There are often occasions when families are pushing for admission of an elderly patient, and I will say, "You know, hospitals are dangerous places. They serve a role for acutely ill patients, but if you can take mom/auntie/grandma home where she'll receive the same medicine, she'll probably be safer." The responses are all over the map, but it furthers the discussion. Many families are just tired and need respite.<br /><br />I wish that I thought that doctors and nurses trying harder and paying more attention would hospitals safer places for older patients. My experience is that we work in the belly of the beast, and have to struggle against the constraints of our institutional bottom lines, which are driven by healthcare finances and insurance reimbursement. Doctors and nurses try valiantly every day to speak to issues of safety, yet even in many proactive institutions, the safety record doesn't improve easily. My best sense of the path forward at this point is that we need to flip the hierarchy which has physicians at the top, to one which is team-based in real time, along the lines of what the authors in "Why Hospitals Should Fly" discuss. As the airline industry learned after the tragedy of Tenerife, the lowly flight engineer, or stewardess, needs to have the ability and confidence to abort the flight before tragedy ensues. Ditto the housekeeper, the aide, and the nurse. Scott Marsland, RNC, FNP-StudentScott Marslandnoreply@blogger.comtag:blogger.com,1999:blog-20352591.post-85504148087051950932013-08-20T09:56:19.249-04:002013-08-20T09:56:19.249-04:00Thank you for your informative and compassionate b...Thank you for your informative and compassionate blog. I think you will find this discussion interesting on a state of the art method of working with people living with dementia in Denmark. Here is a link to Michael Enright's interview on the Sunday Edition. With appreciation for your blog, Trudy<br />http://www.cbc.ca/thesundayedition/shows/2012/11/14/redefining-dementia-in-denmark/index.htmlTrudy Bhttps://www.blogger.com/profile/08978009684800830862noreply@blogger.comtag:blogger.com,1999:blog-20352591.post-61704795953016764722013-08-06T00:40:09.992-04:002013-08-06T00:40:09.992-04:00interesting clarification about resistance, both i...interesting clarification about resistance, both individual and social/cultural/institutional. having the necessity and the situation broken down to three steps could possibly make it happen... but people have a hard time even thinking that far. i wonder if it would work better encased in some ritual context, with support for all parties.firao@fastmail.fmnoreply@blogger.comtag:blogger.com,1999:blog-20352591.post-23056350011413167412013-07-02T00:29:11.599-04:002013-07-02T00:29:11.599-04:00Thank you, thank you, thank you. What a thoughtfu...Thank you, thank you, thank you. What a thoughtful and brilliantly crafted summary of the inchoate thoughts rumbling through my brain. I was shocked to read a tweet a few days ago that Nelson Mandela had been put on "life support." What?? And he's been in "intensive care" for these last three weeks, even though it's nearly two weeks since the hospital announced that they were "keeping him comfortable." One doesn't need intensive care to be kept comfortable. As a surprisingly private man, Mandela is said to have wished for a quiet death and a quiet funeral. Sometimes, of course, public figures must submit to the public's needs; for example, it seems unlikely that Madiba will be granted a private funeral given the wishes of his nation and the public grieving that has already begun. Yet I'm encouraged by your note that even Pope John Paul II rejected heroic treatment when his natural life was drawing to a close. Apparently even public figures at least do not owe it to their public to prolong life in unfruitful ways. Those of us in private life already know we are lucky enough to have the power to make choices that suit us, if we make those choices soon enough to document our decisions for the future. I hope everyone reading this will be sure to complete an "advanced directive" (if one doesn't already exist) to specify personal preferences, especially any unlikely to match the prevailing ideas of family and/or medical practitioners.<br /><br />So happy to have been directed to your blog by the recent NYT article. What a find. Again, thank you.Anonymousnoreply@blogger.com