During a recent lunch with my daughter, a senior at the University of Maryland, she shared her frustration with a question she often receives: “So, what are your plans for next year?” She commented that while her life experiences through present day have been memorable, each stage has been predictable. Now, for the first time, she has more questions than answers. This ambivalence -- this fear of what’s ahead -- ...

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Allow me to describe a recent case and ask your opinion.  Today, you are the intake nurse at hospice and you are asked to evaluate Stan.  This gentleman has incurable cancer, but treatment would probably prolong his survival.   However, Stan has refused that treatment and been referred to you.  It is your job to decide if he is “hospice appropriate.” Why has Stan refused therapy?  It is not that he denies ...

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It was probably the most awkward question I had been asked before, and I did not have an answer. He was a middle-aged gentleman, neatly dressed -- very simple and unassuming. He blended like a lifeless statue in the waiting area. What sparked my notice of him was his accompanying robust file, crammed with familiar pink discharge slips from the ED. He was clearly what we call a “frequent flyer,” but ...

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An innovative study in JAMA Internal Medicine on surrogate decision making has profound implications for how we take care of older hospitalized patients.  The study, by Lexy Torke and colleagues at Indiana University, systematically described the involvement of surrogates in decision making for hospitalized patients. Surrogate decision making refers to the phenomenon in which someone other than the patient is making or helping to make the key medical decisions.  In older ...

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Several years ago I took care of an elderly woman in the ER.  She came in with a chief complaint of chest pain.  She came in via ambulance and by the time she got to the trauma bay she said she was feeling a little bit better.  She didn’t know she was about to die, usually people who are about to die look much worse. She looked good, all things considered.  ...

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He does not want to talk to me, that much is clear. He has had enough of doctors. He is a man of few words. His eyes do not meet mine. His coarse, calloused farmer’s hands play purposelessly with the starched white of the hospital bed sheet. The gentle hiss of his oxygen is barely heard over the hum of the city traffic below. Out of his element. “Tell me, what ...

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Movements come and movements go.  To be memorable, to last, depends on continuously refining the message.  The brand, by necessity blindingly clear in the beginning, must be anything but static.  Ideas mature, knowledge grows, and movements pivot.  They must pivot. The meteoric rise of hospice and palliative care has had untoward affects.  Specifically, the treatment of pain and suffering has dislodged itself from the moors of clinical medicine.  A new generation ...

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In 2005, my husband and I bought a small farmhouse in northern New England next door to Tom and Sally. They were in their early seventies, married nearly fifty years, with a large family. Tom's grandfather had built a farmhouse in 1900 on the family's small pig farm. In the 1970s, Tom and Sally had parceled off the land and built a modern house for themselves, a stone's throw from the ...

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Over the years, many people have shared with me their disappointment at the lack of acknowledgment from their physician when their loved one died. Especially, when their loved one had been a long time patient of the physician. In fact, many people have shared that they switched physicians because of what they perceived as a slight. When people go to a physician for many years, especially the family physician, it is ...

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Today, I hesitated to refer a patient to hospice. The patient is perfect for that model of care.  She has strong family and friend supports, multiple opportunities to maintain quality, independence and dignity, and while she has a disease we cannot fix, she will do very well with personal palliation. Nonetheless, I almost did not recommend hospice, because I realize that hospice is going to completely fail to take care of a ...

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