Discover and read the best of Twitter Threads about #hpm

Most recents (13)

A Tale of “It won’t hurt to try...”

85+ y.o 👴🏻 h/o HFrEF, moderate to severe dementia presents to ED from ECF w/ SOB and AMS. + for COVID 1 week prior.

Patient has documented wishes for DNR/DNI. Initial goals of care convo in ED with son acknowledges those wishes.
Hypotensive in ED, BPs in 70-80/50s, requiring NIPPV. Patient was confused but calm and able to recognize family.

Son voiced that he didn’t want his dad to suffer. MD offered plan of 24-48 hours with pressors if needed & NIPPV to see if pt will improve.

What could it hurt?
Son agreed to plan.

It won’t to try! Right? If he doesn’t get better, do comfort care then.

CVC placed for pressors—-> iatrogenic PTX——> Chest tube

Slightly AMS from baseline—-> acute hyperactive delirium

Pt dies alone in ICU. Son shocked guilty & full of regret
#hapc #hpm
Read 3 tweets
Hospice docs, NPs, nurses, aides and caregivers NEED YOUR HELP
With #COVID, in person Face to face visits are NOT SAFE.
#HPM #PalliativeCare #ACHPN @AAHPM #NoFTF

Your caregivers hope is to get waivers to eliminate FTF or make telemedicine visits an alternative ASAP:
1)Will save hospice patient lives (and minimize spread to families visiting them from across the country)
2)Will save physician/nurse practitioner lives
3)Will allow physicians/nurse practitioners to focus more time on medical needs (Most hospice docs/NPs are #PCP docs/NPs)
4)Will reduce waste of scarce personal protective gear
5)Will have NO impact on CMS finances (no evidence these regulatory requirements save money)
Here is the letter our groups sent: bit.ly/2Wu2DPI
Read 7 tweets
Some time ago, I saw a pt with severe untreated suffering at #EOL alongside aggressive & unproven life-prolonging interventions. When I asked the medical team, they said they were doing “what the family wanted.”

Sharing some of my thoughts about this below 👇🏾👇🏾👇🏾
1/ Rejecting paternalism does not imply that we take ourselves out of the decision making process altogether. We should always work together with our pts & families rather than just “doing what they want.”

#hpm #hapc #bioethics
2/ We should move towards a “deliberative” rather than an “informative” model of decision making. Pts should share values/expectations & we propose medical treatments. It is crucial for all HCPs to have better training on having #goalsofcare conversations.

#hpm #hapc #bioethics
Read 7 tweets
@thetestlabsio I tried to respond to your question with a thread of 10 tweets, but somehow they seems to have become jumbled. I'm re-posting below: slightly generic answers, because so many people ask exactly what you are wondering, and I hope it might help them, too.
Thread ⬇️
I wish someone could have explained her dying to you as it was happening. This might help:
1. Most people move into deeper unconsciousness as the process of dying proceeds.
2. To begin with, they are simply tired & need more sleep, dozing between short periods of being awake.
1/
3. Gradually, they lose consciousness, initially only for short periods during sleep. They report 'good sleep.' We don't know when we are unconscious.
4. When the brain is unconscious it reverts to automatic breathing cycles: alternating deep/shallow, fast/slow, in cycles.
2/
Read 11 tweets
1/ So I got quite a bit of "pushback" when saying that I would probably/most likely/am considering no longer using the joined # of #hpm or #hapc ... when tweeting about #PalliativeCare exclusively...

I also said I would explain myself to those wondering why...
2/ Quick disclaimer: I will entertain thoughtful discussion and opinions in this thread...

I won't entertain one sided views that try to shut me down with that "I'm big & your small, I'm smart & your dumb..." talk

I am expressing MY thoughts, keep your gaslighting to yourself
3/ One of the #CAPCSeminar19 keynotes was on messaging and how we brand ourselves.

It was a great conversation with Diane Meier and Mark Ganz (intentionally not tagging them) with the sharing of ACTUAL CAPC data but also ACTUAL life stories involving Mark's parents.
Read 15 tweets
@RThienprayoon's tweet about this award resonated with me, though perhaps for different reasons. Like her, I had a tough early career step in #hpm #hapc. The first program chief my hospital had ever had, but isolated from a collegial network and with little local support. 1/7
Add in a late start to fellowship, and then 2 years of #miscarriage, #recurrentpregnancyloss and secondary #infertility. Those experiences made me a much better person/doctor/leader/human being, but let's be honest, weren't great for my early career leadership development. 2/7
Early #workingmomlife was a blur of hard work, sleep deprivation, disenfranchised grief, and lessons learned. The transformation was happening, but I couldn't see it. Not until I landed in a more supportive environment. #womeninmedicine 3/7
Read 8 tweets
Latest opioid idiocy:

I prescribe opioid analgesics for a 30-day supply, taking patients' individualized care into account.

Pharmacies & health insurers are now ALTERING my Rx instructions, so that the quantity prescribed fits their auto-calculation. #hapc #hpm (1/_)...
For example, if I prescribe oxycodone 5 mg orally up to every 4 hours AS NEEDED for severe cancer pain (QTY #90 for 30 days, based on the patient's usual usage), then the health insurer or pharmacy calls to request we change to a quantity of #180 or TID dosing. #hapc, #hpm (2/_)
This means that the patient either receives an excessive quantity (i.e. over-prescribing) or incorrect dosing instructions, just to accommodate the auto-calculation used by the health insurer or pharmacy to fit into the state PDMP. Neither option is correct! #hapc #hpm (3/_)
Read 4 tweets
@magthenomad @RachaelHeitner Differences in Penetration Rates - Teaching Status: Teaching hospitals see an average of 5.2% compared to 6.0% of programs in non-teaching hospitals
@magthenomad @RachaelHeitner Differences in Penetration Rates: Consult Triggers: Hospitals with automatic screening criteria see an average of 6.2% compared to 5.1% for hospitals without it in place
@magthenomad @RachaelHeitner Differences in Penetration Rates - Program Maturity: programs who are three years old or less see an average of 4.4% compared to 5.7% for programs who are four years old or older
Read 9 tweets
👇🏼Thread

It’s been ~48 hours since Kathy last expressed a desire for ice chips or water.

Once I stopped giving her dexamethasone, her thirst stopped.

1/
She’d been taking the dexamethasone for referred pain (pain in her shoulder and back) caused by the liver metastasis. Stopping the dexamethasone doesn’t appear to have increased her discomfort any.

2/
It’s been about a week since @Kathy_Brandt last asked for food.

I haven’t offered any to her after that.

3/
Read 16 tweets
Wrote this piece with the help of a great team including @DrKevinHill. Below I'll share some of my thoughts about #opioids and opioid use disorder and how they present in #hpm and #palliative care, plus why we need to do a better job of addressing #addiction at end of life. 1/x
2/x Training in #KY gave me a front row seat to the #opioidcrisis. With an interest in #hpm I kept wondering what would happen to these individuals who developed an OUD and years later were prescribed opioids. How would I keep those patients safe and manage their pain?
3/x I continue to think that our field will struggle in years to come when survivors of the #opioidcrisis age, develop serious illness, and develop pain. Thinking about this, and reading @jeff_deeney article in @TheAtlantic theatlantic.com/health/archive… made me want to do more.
Read 13 tweets
Citation counts come from OTHER RESEARCHERS. They are important, yes.

But, sharing #science on #SoMe=broad & instantaneous dissemination to those who focus their time AT THE BEDSIDE. Which may surprise some- but is MOST OF MEDICINE especially....#anesthesiology.(Thread) #AUA2019
A metric like the “Kardashian Index” *MAY* be relevant in genome biology where the proportion of basic/translational science is significantly higher and no immediate bedside application for a general practitioner is there. (and I’m making an assumption here) #medtwitter #aua2019
When your #research is relevant primarily to other #scientists who are also writing research papers then citation counts do more wholly reflect the paper’s impact. But in clinical research, it’s different. Bedside clinicians are looking to the literature for guidance & new ideas.
Read 13 tweets
What is Palliative vs Hospice?

Pal Care & Hospice clinicians helps patients who have life limiting diagnosis - end stage heart, lung, kidney, liver failure, metastatic cancer or progressive Neuro dz like dementia, Parkinson’s, MS, ALS or severe strokes.
2/ the difference between Palliative & Hospice is that the patients still under Pal Care are in a disease modifying stage of their illness - meaning the train has left the building but we can still intervene to change the path their dz takes
3/ Hospice patients underlying life limiting disease EITHER has NO more disease modifying treatment available OR they elect NOT to pursue further treatment. That doesn’t mean we don’t still treat other correctable reversible issues - we still give abc, fluids, pain meds, oxygen.
Read 12 tweets
1/ There’s no debate- #palliativecare doesn’t hasten death, in fact for cancer pts it prolongs life. Even #palliative sedation doesn’t hasten death! The myth that a palliative approach shortens life (e.g. via opioid use) and is “giving up” is something we combat everyday.
2/ These “palliphobias” can lead to delayed symptom management, prognostication and advance care planning- this problem is very dangerous and pervasive, whether the patient wishes to die via #MAID or not. Not at all against #MAID at all but it does differ in intent.
3/ Anecdotally- have had several cases where well-meaning specialists didn’t recognize #palliative needs early. By the time we saw it was too late to request MAID, pt had lost capacity and had suffered greatly. No one had talked about EOL planning before me! #hpm
Read 3 tweets

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