Thursday, January 28, 2010
Separate Church and 8.
The film, called "8: The Mormon Proposition," had been expected to be among the most controversial to screen during the Sundance Film Festival this year, and a demonstration had seemed likely for some time. It was unclear until Sunday, though, whether another group in support of the California ballot measure would also make an appearance outside the Racquet Club during the premier.
The demonstrators on Sunday chanted the slogan "Separate church and 8," a play on the phrase "separation of church and state." They held signs with the same slogan. The demonstrators were in earshot of the people heading to the film. There did not appear to be anybody from Park City or surrounding Summit County standing with the demonstrators, who seemed to be primarily from the Salt Lake Valley or elsewhere in Utah.
Rick Bickmore, who is gay and from Salt Lake City, said he would like to be married someday and he was disappointed when the ballot measure passed in 2008, even as he said his sister, a Californian, voted for the proposition.
"Our idea here is to be here with dignity," Bickmore said.
Health Care Reform and Palliative Care.
Why are we not likely to see the influence of palliative care advanced during the health reform period? Two reasons leap to mind.
One, hospitals and hospices are the most prominent, and frequent, sponsors of palliative care programs, and we know what’s happening to their reimbursement (it's getting squeezed, with no end in sight). So, as these provider organizations are forced to tighten their belts, is it reasonable to expect (especially in light of the heightened priority on patient safety ) hospitals to increase their financial support of palliative care services? Furthermore, it’s unlikely that the financial performance of hospices will dramatically improve anytime soon. So, we shouldn’t expect a legion of hospices across the nation committing greater resources to palliative care services. It’s not that hospital and hospice executives are tone-deaf to palliative care. It’s just that these executives are faced with budgetary trade-offs and palliative care is not (yet) a high priority.
Two, primary care continues to be undervalued within the American medical system. Will these prevailing views change? Of course. Anytime soon? Unlikely. American primary care is in shambles, and it is now clear that it will not be viable in the future unless significant changes occur in our national attitude about its value and in the way we pay for it. While in other developed nations, 70-80 percent of all physicians are generalists and 20-30 percent are specialists, in America the ratio is reversed, the result of a payment system that has evolved to reward expensive care and penalize proactive management, even though the data are unequivocal that more palliative care (according to the Dartmouth Medical Atlas) within a community results in lower costs and better late-life care.
Rape Victims and the Conscience Clause.
The rights of a hospital, pharmacy, and health care professional should never be allowed to supersede the rights of patients — especially women rape victims. It isn’t the well-being, health, or future life of that health care worker that is at stake. It is the woman rape victim’s.
And every pregnancy is a potential threat to a woman’s health, well-being, and life — including her economic well-being. Anyone from a nurse to a doctor to a pharmacist to a lawmaker or a judge who deprives a woman of the choice to prevent a pregnancy, to end a pregnancy — especially as the result of a rape — should be forced to contribute to the support of every unwillingly pregnant woman and to both mother and child after that fetus becomes a post-born child.
Rape victims who are ER patients should not be made victims again by hospital staff and religious organizations — especially religious hospitals that qualify for tax-exempt 501(3)(c) status for whom the public at large must pick up the shifted tax burden tab.
There is nothing decent, caring, or moral about forcing a physically and emotionally traumatized woman to risk pregnancy or track down an emergency contraception provider. There is nothing moral about stopping a rape victim (or any other woman) from preventing a pregnancy she does not want, or cannot endure.
Rapists do not have a Constitutional right to force a woman to breed for them and ER staff, hospitals, et al, have no Constitutional right to force rape victims to bear their rapist’s progeny.
Opioid Use for Elder, Chronic Pain Relief.
As noted on the Pallimed blog, a study published last week in Annals of Internal Medicine reports on adverse events associated with the prescription of opiates for chronic non-cancer pain.
In brief: they studied 9940 HMO patients (mean age 54) who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005. They used ICD codes with subsesquent chart review to identify "opioid-related overdoses", and found 51 events, of which 6 were fatal. After stratifying by categories of opiate exposure, they estimated that annual overdose rates were 0.2%, 0.7%, and 1.8% among patients receiving less than 20 mg, 50 to 99 mg, and more than 100 mg of opioids per day, respectively. (For more journal-club style details and analysis, check out the Pallimed post, which is good reading for those with a little more time and interest.)
I'll confess that when this article caught my eye, one of my first thoughts was "Argh! Now it will be even HARDER for me to persuade my elderly patients to try a little low-dose opiate for their severe arthritis, when all else has failed to control their pain."
Yes, it's true. I have some of my arthritic elders taking a little daily opiate for their pain: it allows them to walk around a little more and maintain their function, or so I tell myself.
But what do the rest of you think? In particular I'm curious to know what the primary care clinicians among you prefer to use for chronic noncancer pain in frail elders. And how easy do you find it to address the patient's (or often, the family's) worries about the risk of addiction or overdose? Will this latest study change your practice?