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My 80 yr husband has multiple myeloma. He won't eat. Can walk, but lies in bed or couch all day. Dr. will not discuss 'stage'. I know he is failin?

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ILF vs ALF vs SNF: Do You Know the Difference?

Recently, an elderly resident suffered a cardiac event while while eating at home.  What makes this daily, if not hourly, event national news is that she had her event in the dining room of her independent living facility, which, by law, is not required to provide any medical assistance.   Despite fervent pleas by the 911 operator to perform cardiopulmonary resuscitation, the resident services director (apparently a nurse) refused to do so citing corporate policy.

Remember that an independent living facility is very different from an assisted living facility which, in turn, is very different from a skilled nursing facility (commonly referred to as a nursing home).  An ILF is most like any apartment complex and provides no medical services or assistance w/activities of daily living.  In contrast, an ALF provides assistance w/ADLs  On the other hand, a SNF provides around-the-clock skilled nursing.

So be very clear where you're going to live.  Is it an ILF, ALF or SNF?  What services will they provide?  Cardiopulmonary resuscitation?  More importantly, do you have your paperwork in order?  If you don't want CPR, do you have readily accessible paperwork stating as such?  And do your family members know what you (don't) want to have happen?

Caveat emptor.

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My mother is 88 yrs old with dementia. She recently stopped eating. She will only take a few bites. What can I do?

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Should I let my mother, with dementia, live on only apple juice and coffee?

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I have an 83 yr old diabetic alzheimers patient takes 70 ml insulin daily and has done so tonight.blood sugar is 583.

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Will they give you enough morphine if you are at the end to keep you pain free?

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Re: Chemo, my dad is 80 years old with lung cancer, stage 3, the chemo is killing him. he lost 14 pounds since we started

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How low can he weight and still live?

Hospice & Palliative Care for Prostate Cancer

As a follow up to yesterday's discussion about the last 6 months of life in those with heart failure, the Archives of Internal Medicine also published a study looking at the use of hospice in men dying of prostate cancer between 1992 and 2005.

The good news is that just over half (54%) were enrolled in hospice.  The bad news, the average length of stay prior to death was just 24 days while one in four enrolled within seven days of passing.  So yes, the message is getting out to offer palliative care but it's not getting through early enough.

As physicians, we are trained to save lives.  So we continue to offer medications, therapies, and surgeries, even when faced with certain death, because to do otherwise would be to admit defeat.  It's time that patients, families & physicians realize and admit that death cannot be defeated.

Despite what you may read or hear about immortality moving within our grasp, that is not the case.  So to encourage thinking otherwise is disingenuous for everyone involved. Instead, even as we first attempt a cure, we should also be just as focused on offering palliative care to counter all the symptoms and side effects of said therapy.

And we should initiate a discussion as to when to focus less on cure and more on caring, with the possibility of transitioning to a hospice facility when the staff there can do the most good in preparing the patient and family for one of life's certainty.  As noted two weeks ago, there are studies that demonstrate higher quality of life and prolonged survival in those patients who elect hospice care over narrowed focused continued attempts at cure.

Hospice & Palliative Care for Heart Failure

Heart disease remains the number one killer of both men & women in the US.  However, not everyone dies a quick & sudden death from a massive heart attack or dysrhythmic collapse.  Instead, due to the modern miracles of medicine, many suffer for an inordinate number of years with damaged hearts leading to heart failure while one in four die within the first year after the diagnosis is first made and one in three die within a year of hospitalization for heart failure.  In fact, heart failure accounts (at least partially) for one in eight deaths.

Given the grim statistics above, it's imperative that we start talking to our patients about their goals and their desires for (specific) treatment soon after, if not immediately upon, diagnosis so that even as we work to mitigate the complications of heart failure, we can also palliate the symptoms in a fashion consistent with the patient and family's desire.

Towards that end, two studies were published last month looking at the cost of care during the last six months of life in the US and in Canada over the past decade or so.  Given our general love of the care offered by our neighbor to the north to all her citizens, it's surprising to me that there were more similarities than differences.  Surely, the way medicine is practiced has changed during this same period of time, something documented in both studies.  But importantly, only one in three in the US died in the hospital with hospice use increasing over this period of time, coincident with a surge in the number of hospitals with palliative care programs.

We're not there yet.  We're still not optimally caring for our dying, once it's clear that death is imminent in the next 6 months or so.  But we're slowly getting better.

Shhhh . . . What About Hospice & Palliative Care?

I try to focus this blog on health rather than disease by writing about all that we can do to optimize our wellness.  But death is the 800 pound gorilla in the room.  We can't escape its grasp, yet too often, we ignore it and won't discuss it, even when it's near.  It's as if by mentioning it by name, we're committing someone to a sure death.  But I have a surprise for you:  even if we don't talk about death, we will still die, sooner or later.

Sure, physicians and lay people alike aren't very good at using their crystal balls to predict the exact time of death.  But with certain diseases and conditions, we've developed enough experience to narrow our guess down to weeks-to-months or sometimes days-to-weeks or so on.  You get the idea.

Cancer is one of those illnesses where we can often make a credible guess.  Yes, we've made tremendous strides over the last few decades against this dreaded diagnosis.  In fact, some forms that were once as good as a signed death sentence are now manageable.  With others, we even dare breathe that other "C" word, cure.  But still too often, cancers either present too late, having already spread to different parts of the body, or become resistant to all the surgeries, chemotherapies, and radiation that we can throw at it.  

These patients, the ones with metastases, are the ones for whom we should discuss hospice and palliative care earlier rather than later.  Realistically, we should offer palliative care even at the beginning of any treatment to help all patients and their loved ones cope with side effects and adverse reactions.  But later on, once it's clear to us, the physician, that things aren't going so well, rather than consider death the equivalent of defeat, we really need to take the initiative and start discussing hospice & palliative care, even as we consider another "Hail Mary" pass to rally the troops.  In truth, we never win.  Death always trumps life.

The American Society of Clinical Oncology just released a new statement that care needs to be individualized for patients with advanced cancer.  That's code for actively involving the patient in his/her care, specifically asking for their individual goals and care preferences.  For many, it's not death that is feared, but rather the final days right before.  Patients don't want to suffer (however, one defines that physically, mentally, emotionally or spiritually) or to be left alone in the hospital's cold sterile environment.  Most want to be at home surrounded by loved ones after having checked a few more items off the bucket list.  This is where hospice and palliative care medicine step in, to offer comfort and compassion, when no cure is possible/realistic, to both the patient and the family.

Incredible as it may sound, in the case of metastatic non-small cell lung cancer, in a study published in the New England Journal of Medicine last August, those patients randomized to early palliative care had less aggressive care at the end of life (as expected by definition), yet reported better mood, better quality of life, and surprisingly, longer survival, living on average almost 3 months longer (11.6 months compared to 8.9 months) compared to those who received standard oncologic therapy alone.

So it's about time that we acknowledge that 800 pound gorilla.  To get the conversation started, a nice piece was written online yesterday in the USA Today.  Let's start talking about hospice and palliative care options.

Disclaimer:  I serve as a Medical Director for Infinity Hospice Care's Las Vegas program.