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I have been receiving announcements regarding seminars on having conversations about end of life care. Several months ago, I led an interactive seminar on asking the questions that start the conversation. The assumption is that everyone wants to have the conversation when we do. Read the rest of this entry »

The Rehab Back Door


As a palliative care nurse practitioner in a large academic medical center, I’m dismayed when some of my frailest patients get discharged to “rehab”. It seems unlikely they will be able to effectively participate there, so what happens is those who can’t end up becoming long-term care or nursing home patients through the rehab back door.


I can understand patients and families wanting to pursue rehab. It sounds so promising: a chance to gain enough strength to resume their previous lives. But, as I’ve blogged before (, that hope is unrealistic for many. And the transition to long-term care/nursing home status can be abrupt. Rehab facilities are required to make a regular determinations of a patient’s performance and so, from one day to the next, patients can “fail” rehab. Reviewing the literature, it looks like 20-30% of rehabilitation patients do so and become long-term care residents. (This is actually a very difficult area to search because there are so many different post-acute options and the patient population is heterogeneous.) In my experience most would refuse to be discharged from the hospital to a nursing home but go willingly to rehab.


Part of the problem, again, is that we don’t talk about this possibility in the hospital or when we send patients to rehab. Instead, that falls on our colleagues working in long-term care. I recently met with a wonderfully progressive team at the Genesis Spa Creek facility outside of Annapolis, Maryland . They shared the difficulty they have as the ones who finally have to break the bad news to patients and families that they are not able to go home and that a nursing facility is their only option. Many patients had begged their families never to send them to a nursing home, yet that is where they are.


So, my apologies to my long-term care colleagues and to the patients and families who sign onto rehab but end up in nursing homes. Post-acute care is a hot topic in healthcare reform and hopefully someone will come up with better options and transitions for us all.

The Show’s Over

"The show's over," he had muttered several times. Whether he knew it or not, he was telling her it was time. Maybe it’s just that simple, though we usually don’t allow it to be so. Read the rest of this entry »

The fine line between son-in-law and doctor-in-law: by Nicky Quinlan, JPM Fellow-in-Training Columnist

Daisy is 68. In the past few years, she has experienced life with a neurological condition causing progressive functional decline, pain, visual impairment and other indignities. Surprisingly to me, she cut a rug into the wee hours at my sister’s wedding in Ireland recently. Other days, she sleeps a whole lot and needs much assistance with mobility and ADLs from her loving, dedicated spouse, Abe. Her spirit remains strong, however. Daisy is also my mother-in-law. Read the rest of this entry »

JPM Honors All Mothers Worldwide: Happy Mother’s Day

The unconditional love and compassion that is the cardinal aspect of a Mother's expression of her caring is also a key premise of palliative care. We take the opportunity today to thank all mothers worldwide for teaching us the caring and compassion we show all our patients and families. Read the rest of this entry »

“If the good Lord calls me home…”

Mary’s eyes widen, she all at once thinking that what she had thought was what anyone else might think. Until, of course, it’s your turn to think. “It’s not like on TV,” I say, pausing for an answer that doesn’t readily come. “We’ll put a tube down your throat,” I continue, after waiting, “let a machine breathe for you,” her eyes, made wise by 95 years, suddenly recognizing what had not before been obvious. Read the rest of this entry »

Gen X Family Caregivers

By 2030 there will be 3 seniors for every "kid." And in an age of divorce, the caregiving complexities go up by the square (step-parents, half-siblings, step-siblings...). Nearly half of Boomers have been divorced, so their kids now have 2 households to juggle. And many men are estranged from their children. In the divorce, "mom kept the kids," physically and emotionally. Read the rest of this entry »

American Board of Internal Medicine releases new MOC module on Hospice and Palliative Medicine

We have achieved a huge milestone for palliative care. Earn 10 MOC credits by completing of the new ABIM Hospice and Palliative Medicine Self Evaluation Module! This module consists of 25 multiple choice questions, rationale for the answer choices for each question and a set of references. Read the rest of this entry »

Palliative Care in LA Times

LA Times columnist Steve Lopez profiles a gentleman with end-stage cancer who, along with his family, is receiving palliative care support at home–“Not Ready To Die, But Prepared”. In this December 4th piece, Mr. Lopez also references some palliative care research, health care policy implications and questions why palliative care and hospice are often not positively represented in political discourse on these subjects.

While at the LA times site, its also worth reading Mr. Lopez’s other, more personal piece, “When Death is Certain, but Dignity is Not.”  In response to his story, many readers have responded with their own.

Be Still

I would like to share some of the art I created during training as a way of reflection and self care . Read the rest of this entry »

Dying Cancer Patients

Dying cancer sufferers should not be given “futile” and expensive drugs, experts have said in a warning over the “culture of excess” in treating the disease..... Read the rest of this entry »

When a parent is ready to let go, but the child isn’t

I see now, even long before her actual death, she was letting go. It was natural for her, not scary at all. More of her time was spent in her internal environment–meaning inside herself. As a healthcare professional who had worked with older individuals, this made absolute perfect sense. But as a daughter, it was hard to understand and accept that she was in the process of letting go, of, well, dying Read the rest of this entry »

Long Term Care of Older Americans

Great video about long term care options. May help clinicians unfamiliar with Geriatric care as well as families looking to better understand long term care. Read the rest of this entry »

World Health Organization report on Palliative Care for Older Adults

Looking for a document to use to spread awareness of palliative care?

The World Health Organization has recently released a report entitled Palliative Care for Older People: Better Practices (2011). It provides an interesting review of palliative care services throughout Europe (including a description of integrated palliative care in four Eastern European countries), and it includes sections on dementia, palliative care in the nursing home, and family caregivers. Of special interest is the description of England’s End of Life Care strategy, which includes advance care planning and coordination of care across settings.

Burdensome Transitions: Harry Potter and Health Care Reform: by Joan Teno, MD, MPH

Based on research and my clinical experience, my concern is the financial incentives of Medicare and Medicaid result in some health care providers hospitalizing NH residents to qualify them for SNF Medicare benefits. My fear is what you pay for is driving force in these health care transitions. Often this is not an explicit decision, but the middle-of-the-night reflex act of sending a frail, older patient to the ER. Read the rest of this entry »
Can We Talk?
Watch and share this five minute video about the need for prophylactic end-of-life conversations. Laura Heldebrand, an ICU nurse tells her mother's story.
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