Mar 2, 2016 #hpm chat with Dr. Kevin Madden
9:00 pm21:00

Mar 2, 2016 #hpm chat with Dr. Kevin Madden

by Kevin Madden, MD

Just as in any medical specialty, there are “bread and butter” aspects of Pediatric Palliative Care – situations we encounter on a frequent basis that we are quite comfortable in dealing with.  Pain management, constipation, family meetings, resuscitation status and discussions about goals of care certainly are at the top of that list.

Well, I’m a zebra guy. 


Remember the old medical saying “when you hear hoof beats, think of horses not zebras”?  I’m a zebra guy.  I’m endlessly fascinated with the obscure, the rare and the unusual. 

This week’s Tweet Chat will be on topics that we do not confront with on a daily basis but will come across at some point in our careers.  Since they are infrequent, they lend themselves to a group discussion where we can learn from each other’s collective experience.

Dr. Kevin Madden is a palliative care physician at M.D. Anderson Cancer Center in Houston, Tx. He specializes in Pediatrics, and his research interests include opioids in children with advanced cancer. 

T1:  Pediatric Delirium: How do you diagnose delirium in a child?  Should we screen for delirium in children?  How do you treat delirium in children?

T2:  Outside the Box:  The use of non-traditional medications and non-traditional routes to alleviate suffering.  What have you done that the rest of us can “put in our back-pocket” to be able to use in a crisis or unusual circumstance?

T3:  Pediatric Palliative Sedation:  When do you consider palliative sedation therapy in children?  What medications do you use?  What ethical dilemmas have you encountered?

What: #hpm (hospice and palliative med/care) chat on Twitter

When: Wed 3/2/2016 - 9p ET/ 6p PT

Host: Kevin Madden MD Follow him on Twitter @madden_kevin

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using for ease of following. You can also check out the new site dedicated to #hpm chat -

Outpatient Palliative Care with Dr. Kimberly Curseen
9:00 pm21:00

Outpatient Palliative Care with Dr. Kimberly Curseen

by Kimberly Curseen

As the field of palliative medicine expands much attention and resources have been placed on inpatient consultation, with very positive results for patients and the health care system. We can now see access to inpatient palliative care is becoming a standard. The natural progression is to then extend the same important resource to patients in the outpatient setting. Outpatient palliative care provides resources for symptom management for patients and families going through aggressive and maintenance treatments for their serious illness.

Studies for the last decade have been demonstrating the effectiveness of early palliative care in improving patient quality of life and reduction in acute care resource utilization at end of life. Although results of the impact of outpatient palliative care may vary in the literature, it is consistent that these programs improve aspects of quality of life that patients consider to be important.

The Temel study in the New England Journal of Medicine "Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer" is one of the most cited studies showing the impact that early longitudinal palliative care can have on patient's quality of life. Patients were randomized to integrated palliative care with oncology care vs standard oncology care. The early palliative care intervention resulted in improved quality of life and mood in addition to less aggressive care at end of life and possibly prolonged survival for patient receiving the intervention.

A study in Archives of Internal Medicine in 2004 "The Comprehensive Care Team: A Controlled Trial of Outpatient Palliative Medicine Consultation" showed improve outcomes in spiritual distress and dyspnea but not in pain or depression. Another study in the Journal of Palliative Medicine in 2012 "The Impact of an Outpatient Palliative Care Consultation on Symptom Burden in Advanced Prostate Cancer Patients" showed that in their preliminary data patients had improvement in pain, drowsiness, fatigue, depression, sleep, sense of well-being, and anxiety.

In 2013 the Journal of Palliative Medicine published "Moving Upstream: A Review of the Evidence of the Impact of Outpatient Palliative Care" which reviewed the current literature up to that point on the impact of outpatient programs. The evidence supported that outpatient palliative care could "...1) improve patient satisfaction, 2) improve symptom control and quality of life, 3) reduce health care utilization, and 4) lengthen survival in a population of lung cancer patients".

With a growing body of literature supporting the need for outpatient palliative care, in addition to other health professions accepting that earlier integration of these services is important for patients, we as a profession are continuing to discuss how best to meet this growing need. Outpatient palliative care poses a variety of challenges for sustainability. Some of these include:

  • What defines outpatient palliative care? What are the core team members that must be available to patients to be an outpatient palliative care clinic?
  • How does a clinic continue to financially support non-billing members of a team?
  • Does the team assume primary symptom management or write recommendations?
  • What is our role in complex opioid management?
  • Should outpatient palliative care providers have training in addiction medicine?
  • Do patients transition out of outpatient palliative care?
  • How do we interface with primary care providers? Are we the primary providers for the seriously ill?
  • Who qualifies for outpatient palliative care? What defines a "serious illness"?
  • Should clinics be embedded in specific specialty ie oncology, geriatrics, cardiology etc or stand alone?
  • What guidelines are we following for symptom management? Could a patient move around the country and receive the same standard of care from clinic to clinic?
  • Are our fellows adequately trained to assume non-academic outpatient palliative care positions?

Practicing outpatient palliative care has been the most rewarding work of my life and I cannot imagine doing anything else. However, I find myself often concerned with whether my clinic is providing the standard of care our patients deserve. I find myself often with faced with challenging questions about how to deliver effective care with limited resources in addition how to protect these resources in fiscally troubled times. This year at the AAHPM annual meeting in Chicago several members will be attending as exploratory to meeting to develop an Outpatient Palliative Care SIG. I am hoping that it will help develop a network for Outpatient providers to share the challenges and solutions to issues that many of us are facing. (If you are a AAHPM member see AAHPM Connect for more info.)

Please join us for #HPM tweetchat to discuss this very important topic Feb 10th at 9:00pm.

T1: What defines an outpatient palliative care? Is a single provider enough?

T2: What are the challenges to sustainability of outpatient palliative care clinics?

T3: Should outpatient palliative care providers be trained in addiction medicine?

Dr. Kimberly Curseen is an outpatient palliative and geriatrician doc in Georgia working to advance access to quality palliative care for people with serious illness. 

What: #hpm (hospice and palliative med/care) chat on Twitter

When: Wed 2/10/2015 - 9p ET/ 6p PT

Host: Dr. Kimberly Curseen Follow @curseen

Follow @hpmchat for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using for ease of following. You can also check out the new site dedicated to #hpm chat -


Michael R et al. The Comprehensive Care Team A: Controlled Trial of Outpatient Palliative Medicine Consultation. Arch Intern Med 2004; 164(1): 83-91 OPEN ACCESS PDF

Michael R et al. Moving Upstream: A Review of the Evidence of the Impact of Outpatient Palliative Care. Journal of Palliative Care Medicine. 2013, 16(12): 1540-1549

Temel J et al. Early Palliative Care for Patient with Metastatic Non-Small Cell Lung Cancer. N Engl J Med 2010; 363:733-742 OPEN ACCESS PDF

Yennurajalingam S et al. The Impact of an Outpatient Palliative Care Consultation on Symtpom Burden in Advanced Prostate Cancer Patients. Journal Of Palliative Medicine 2012; 15(1): 20-24 NOT OPEN ACCESS

Image Credit: Outpatients via All Rights Reserved

Image Credit: #hpm square by Christian Sinclair for Pallimed. CC BY 2.0

End-of-Life Care around the World with Dr. Ravi Maharaj
9:00 pm21:00

End-of-Life Care around the World with Dr. Ravi Maharaj

by Ravindra Maharaj

A recent large study published in JAMA compared end-of-life practices for people with cancer in seven developed countries from 2010 to 2012: USA, Belgium, Canada, England, Germany, Norway and the Netherlands. The United States had the lowest proportion of in-hospital deaths and lowest number of days in the hospital in the last six months of life. Conversely, over 40% of patients who died from cancer were admitted to the intensive care unit (ICU) in the last 6 months of life (more than any other country in the study by a factor of two.) Something we have seen echoed in previous research.  

Spending for end-of-life care in the hospital was high in the America but not as high as in Canada and Norway. It should be noted that in the figure shown that physician costs are not included in the US figure and therefore should be considered an underestimate.

Chemotherapy use was highest in Belgium followed by the US. The place of death seems to have shifted in the US away from the hospital as in the early 1980’s over 70% of patients with cancer died in the hospital and longer hospital stays were more common.

Besides all patients over 65 with any cancer, the researchers also looked at a targeted population of patients with lung cancer over age 65. The secondary analysis of this more similar group reinforced the patterns seen in the larger group with various cancer types.

2016 #hpm chat squares (2).png

Other commentary on this research can be found in the NY Times and Medscape. The article is not open access at this time. 

Here are the topics:

T1: Are you surprised with the results of the study? If so, elaborate!

T2: How can the US centres reduce end of life hospitalisations and expense near end even further?

T3: What can other countries learn from the US practice? What can the US learn from the international community?

T4: Do you believe dying patients without cancer have similar outcomes?

What: #hpm (hospice and palliative med/care) chat on Twitter

When: Wed 2/3/2015 - 9p ET/ 6p PT

Host: Ravi Maharaj @ravipm2000

Follow @hpmchat for up to date info.

If you are new to Tweetchats, you do not need a Twitter account to follow along. Try using the search function on Twitter. If you do have a Twitter account, we recommend using for ease of following.

You can find past #hpm chat transcripts and analytics on Symplur.

Meeting the Needs of Hospice Patients through Music Therapy
9:00 pm21:00

Meeting the Needs of Hospice Patients through Music Therapy

by Emily Olschki, MA, MT-BC

 “Please check on James in room 24,” the nurse said when I arrived on the unit. “He’s been anxious all day and we’ve got him with a 1:1 nurse.  Katie’s with him now.” James was in his late 80s with dementia. He had come to our inpatient hospice the day before for symptom management after his increasing restlessness led to him falling repeatedly at his assisted living facility. 

 James was fidgeting in his wheelchair with his head drooped down and his brow furrowedAs I sat down and got out my guitar, I watched Katie cue him to stay seated. He picked up his head and nodded when I asked questions to determine the music he liked – big band and jazz.  I started with an upbeat song that matched his restless state then gradually slowed down the tempo as I moved to other songs. When he tried to stand, we’d remind him to sit and listen to the music.

As I continued to play, he began to rock gently back and forth to the beat for short stretches and his face relaxed. Katie slipped away to attend IDT. After several minutes, James closed his eyes and rested back in his wheelchair for a minute.  I paused my singing to see if he was ready to rest, but he began fidgeting with the arms of his wheelchair again. I started another string of songs, beginning with a slow ballad from the 40s, and he sat back again and gradually dozed off. Katie returned and James opened his eyes.

“James, are you ready to take a nap?” she asked.  He nodded and calmly let her help him into his bed.

Music therapy worked in conjunction with medical interventions to decrease James’ restlessness and maintain his safety that morning. Trained music therapists may also work with hospice & palliative care patients to:

·         Increase self-expression, emotional processing, and life review as patients reflect on significant songs and their meanings or engage in music-making   

·         Create positive memories with and leave legacies for their loved ones through songwriting, videos, letters, and in-the-moment interactions

·         Increase physical comfort by addressing pain, agitation, and shortness of breath

·         Help patients and families process anticipatory grief and say goodbye

·         Improve quality of life through emotional and spiritual support, decreased isolation, and connection with interests

Join us for the #hpm chat on Wednesday, January 27 at 9 pm EST to discuss music therapy in hospice and palliative care settings.

Chat questions:

T1. What have your experiences been with music therapists in your health care org?

T2. What do you see as the barriers to accessing MT in health care settings? How do we overcome?

T3.  Qualitative research in MT has shown that MT can increase self-expression (Gordon & Clements-Cortes, 2013), family bonding (Savage & Taylor, 2013), and QOL (Hilliard, 2003). What future research would help MT implementation in more #hpm programs?

Emily Olschki, MA, MT-BC (@EOlschki) is a board-certified music therapist working with adult and pediatric patients at Kansas City Hospice & Palliative Care.

*Names, ages and details changed to protect patient privacy.

Image credit: Kylie Hinde - Music therapist - by Conor Ashleigh for AusAID via CC BY 2.0

Helpful links:

Gordon, M., & Clements-Cortes, A. (2013). Music at the end of life: bringing comfort and saying goodbye through song and storyAnnals of Long-Term Care: Clinical Care and Aging, 21(11), 24-29.  

Setting The Record Straight: What MT is and Is Not by the American Music Therapy Association


How long does granny have, doctor? HPM Chat with Dr. Liam Farrell
9:00 pm21:00

How long does granny have, doctor? HPM Chat with Dr. Liam Farrell

by Liam Farrell

“How long does granny have, doctor?”

“Only a few days,” I said. I was young and beautiful and too green to know that the wise clinician always fudges the prognosis. Within minutes the message was winging its way across the globe.

A few nights later and there were relatives tucked in every corner, swinging on the rafters, hanging from the roof, dangling from the curtains. Not that granny was an angel. To paraphrase Jonathan Swift: true to her profit and her pride, she made them weep before she died. But as La Rochefoucauld observed, we are more often loved for our vices than our virtues, and the relatives had ridden in on the four winds, swum dangerous rivers, climbed huge mountains, endured biting insects and even Ryanair flights. They’d come from Boston, Singapore, Sydney, Vladivostok, all determined to be there at granny’s deathbed.

So I was disconcerted to find granny looking much better, quite perky even. Breaking bad news is all part of the job, but breaking good news was a novel challenge. I’d parked my car on a downhill slope, facing away from the cottage, to facilitate a quick getaway. If it proved a long pursuit, had I enough petrol, I wondered.

“I have good news,” I said, trying gamely to give it a positive spin, “Your granny’s not dying after all. She’s looking much better. Ain’t that great?”

There was an ominous silence, which, inexperienced as I was, I felt compelled to fill.

“Underneath it all, she has a great engine, heart like a lion, strong as a horse, and all,” I continued, starting to babble, hoping that this testament to the clan’s animal virility might soften the blow.

“We were told she was very ill,” accused Boston.

A rebellious muttering began. “It’s cost me a bloody fortune,” from the deserts of Sudan. “My return flight is next weekend,” from the gardens of Japan. “I’ve taken a week off work for this,” from Milan. “I knew there was bugger all wrong with her,” from Yucatan. The crowd shifted threateningly forward, as crowds do when someone has a rope, a nearby tree has a convenient low branch, and the gestalt has a lynching in mind.

“Don’t lose hope,” I said, “I’ve adopted the Liverpool Care Pathway.”

Dr Liam Farrell (@drlfarrell) has been a columnist for many years, for the BMJ and Lancet among others. He was a family doctor for 20 years in Crossmaglen, Ireland, and is a former tutor in palliative care. Follow his Facebook page.

Related Links

Join in the conversation on the #HPM tweetchat this Wednesday, January 20th, 2015 at 9 pm EST, when we discuss the following questions:

Topic 1: Do cancer patients get more palliative care than elderly multi-disease patients? Why is that?

Topic 2: What do patients and families expect of prognosis, especially close to death?

Topic 3: How can we help patients and families prepare for death?

What: #hpm chat on Twitter

When: Wed 1/20/2016 - 9p ET/ 6p PT

Host: Dr Liam Farrell @drlfarrell

Please follow @hpmchat and check for more details. You can access the transcripts and analytics of #hpm chats through @Symplur.

Image credit: Time Clock via Wikipedia

Image credit: hpm chat 2016 01 20 by Pallimed

Image credit: More Care, Less Pathway: A Review of the Liverpool Care Pathway cover