Case 1: You have a 94-year-old woman with multiple medical problems in hospice who develops a fever (subjectively hot to the touch), shortness of breath, and a cough producing yellow sputum.  Her daughter asks if she can be treated with antibiotics "to make her feel better."  The patient is not well enough to make decisions, but in earlier conversations had stated a goal of remaining comfortable at home, while also ...

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Advanced dementia is a terminal illness needing palliative care. Unfortunately, there is a great divide between this statement of the world as it should be, and the current reality of the world as it is.  Rates of pain and shortness of breath are high for patients with advance dementia.  Patients with advanced dementia often reside in nursing homes, and few nursing homes offer specialized palliative care services. And, as we can see from an ...

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What is a natural death, anyway? I get it - death is part of the cycle of life. Seasons change.  The moon waxes and wanes.  We are born. We die.  Death is natural. But what is a "natural" death?  Seriously, what comes to mind when you think of natural death?  Here is a video of a natural death, taken from the Planet Earth series: Death in nature is often violent, brutal, ...

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Here is the setup.  You're working in the ICU.  You want to communicate a prognosis to the family of a patient who is so ill he cannot make decisions.  You sensitively state the facts: the patient has less than a 5% chance of survival.  Or perhaps you say "he will definitely not survive." The family confers, and decides that they want to focus on keeping him alive as long as possible. ...

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"Mom's been writing goofy checks..." "Dad stopped paying his bills...." "Grandma wired her savings to Nigeria..." Have you heard these phrases from the family caregivers of your elderly patients?  Have you ever been concerned that your patient may lack capacity for financial decision making?  How do you decide if they lack capacity?  What is the clinician's role in making these decisions?  What is their responsibility? These important questions are addressed in a terrific new article in ...

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I heard a prominent speaker talk about studies at the National Institute of Aging.  The speaker described several new large and well funded trials aimed at preventing illnesses associated with aging, such as dementia and disability.  These studies are terrific, and worthy of funding. I was disappointed, however, that little was said about funding for studies of older adults already living with dementia and disability.  Research in prevention will not help these patients.  I asked: where is the ...

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"No man, not even a doctor, ever gives any other definition of what a nurse should be than this -- 'devoted and obedient.' This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman." -Florence Nightingale, 1859 Please take a moment to celebrate the nurses in your life. Florence Nightingale was the first to publicly decry the sorry ...

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I was consulted recently about an elderly woman who refused surgery for a large bowel obstruction from a colonic mass, likely cancer. The inpatient team asked me to help with the transition to hospice and to help make her comfortable. I went to see her. She had a nasogastric tube sucking up brown material from her stomach. Her abdomen was swollen and uncomfortable. Her primary goal was to return to walking ...

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Words have power. Language has power. The words we use may comfort or shock, allay or provoke, sooth or batter. Words often imply layers of meaning that are not explicitly articulated, yet rest beneath the surface: “I worry that time is short for you” (You are dying) (I care about you) “I wish we could have done more” (Nothing would have changed her death) (I am on your side) “I hope with you that ...

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On my last day of ward attending, I handed out an EKG that resembled the Dow Jones industrial average over the last 10 years (not pictured). The normal pattern of an EKG was completely disrupted: ST segments were markedly elevated, P waves were hidden, and beats were grouped in odd patterns. My medical team laughed and shook their heads. I asked why. A brave intern responded that he was completely at a ...

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