Protesting a 94 Year Old's DNR.

Oy. Should we really point out the differences between a 94 year old unconscious alzheimer's patient with a DNR order and Terri Schiavo? Or should we just let this reporter slip in a divisive name in order to get the story some eyeballs? How can this be written as anything other than absurd -- all under the guise of fair reporting by representation of "both sides"? And at what point is the media irresponsibly sensationalizing death?

I find this to be some of the most irresponsible reporting -- and a frighteningly sad case. Does the niece expect her aunt to live to be 100? 110? Can death really be cheated? What kind of pain is the patient in? And what is the niece willing to do to prolong her aunt's death? How misguided is this "local right-to-life" group to take up this case with protests -- and to what end? And what good is a medical proxy when any family member or hospital administrator (as seen in other cases) can over-ride decisions? Isn't grieving and decision-making enough effort without protests? And why is the reporter irresponsible enough to allow the commenter to equate sedation with euthanasia?? Absolutely outrageous.

We can only hope that cases like this show the absurd belief we have fostered over the past few decades that humans can live forever; that doctors can perform miracles; that a DNR equals removal from life support or that it signifies anything other than compassion; that life, no matter how pained, frail, aged or afflicted, is worth "saving." And yeah, thanks for listing the address of the elder home.

Family members of an elderly women under a court-ordered "do not resuscitate order" in an Orland Park assisted living center joined members of a local right-to-life group Saturday to protest the court decision, saying their "beloved aunt" should be kept alive by all means necessary.

"This is the dark side of probate court," said Jay Drabik, a nephew of 94-year-old Lydia Tyler, who remained heavily medicated and unresponsive in a room at the Brighton Gardens Assisted Living Center at 16051 S. LaGrange Road.

The case has echoes of the prolonged court battle over Terri Schiavo, in which family members feuded for seven years over whether Schiavo's feeding tubes should be removed as per the wishes of her husband.

In Tyler's case, her brother, James Drabik, and two other relatives authorized a court-appointed guardian to convene an "end-of-life" meeting for Tyler late last month, leading to the "do not resuscitate order," said Lynn Drabik, a niece who joined other protesters Saturday.

Relatives who want to keep Tyler alive dispute a doctor's finding that she is in a state of advanced Alzheimer's and not capable of living independently. Only a month ago, they say, Tyler held a birthday party and posed for pictures with family members.

Attempts to reach Tyler's brother, or an attorney representing him, were unsuccessful Saturday.

Meanwhile, protesters fear Tyler could die at any moment under the influence of strong narcotics meant to ease her into death without pain.

"Nobody wants her to be in pain, but you euthanize pets and animals, not people," said Jay Drabik.

Elder Suicide.

Suicide among elders in nursing homes in Italy has risen.

The survey of Italian seniors living in long-term care facilities revealed that the suicide rate was nearly 19 per 100,000 people. The average rate for seniors over the age of 65 is 14 per 100,000 people, according to researchers from the University of Rochester in New York. Risk factors for suicide include depression, anxiety, and feelings of isolation or loss.

Millions of seniors in the U.S. live in assisted living or skilled nursing facilities. These institutions can help by screening for depression upon admission, monitoring a new resident's adjustment to the facility, and helping to control any pain the resident experiences, according to researchers.

Suicide Risk for Seniors in Care Facilities.

From HealthDay News via Bloomberg:

Seniors living in assisted-living and long-term care facilities may have a higher rate of suicide than those who continue living in their own homes, suggests a new report.

People over 65 commit suicide at a rate of about 14 per 100,000 people, but in a study of Italian people living in long-term care facilities, researchers found that the rate of suicide was nearly 19 per 100,000 people.

One reason may be that stressful or troubling events -- such as death of a spouse, illness or a decline in physical function -- may underlie the move to a residential care facility, the researchers say.

"The risk of suicide may be heightened during the first year," said the report's lead author, Carol Podgorski, an assistant professor of psychiatry at the University of Rochester in New York. "There's relocation stress, and that's when they're dealing with whatever caused them to move."

The report was published online May 18 in the journal PLoS Medicine.

Teasing out the exact reasons that cause the increase as well as developing potential prevention strategies is important because nearly one-quarter of all seniors will live in a residential care facility at some point, according to background information in the report.

More than one million seniors in the United States live in assisted-living facilities, most of them female (about 80 percent), the report said. The average age of residents is about 85 years. Many others live in independent-living communities, long-term care facilities, also called nursing homes, and continuing care retirement communities, which include all three.

Overall risk factors for senior suicide include anxiety, substance abuse, psychotic disorders, social dependency or isolation, family troubles or losses, an inflexible personality and access to firearms. Specific risk factors for older people living in a residential home include being widowed or divorced, having a pessimistic outlook, sleeping more than nine hours a day and drinking more than three alcoholic beverages a day.

Respecting Direct-Care Workers.

It's a little old (April 2) but well worth the read: an article by Beth Baker from Ms. Magazine on the low pay and respect afforded our vital direct-care workers. As our nation ages and as more elders come into the health care system via new laws and new medical advancements in end of life care, and as we work to provide care to all members of society, direct-care workers form an increasingly important wing of our health care delivery system. I think Baker helps initiate the necessary discussion of why these workers are so poorly paid, who makes up their ranks, and how we can work to ensure that their vital work is properly rewarded.

Those who care for our elders continue to be stuck at the bottom as far as wages and respect [PDF], despite rapidly growing need for their services. No matter the setting in which they work—nursing homes, assisted living, individual homes—direct care workers are low-paid, often without health insurance and confronted with back-breaking labor and challenging clients with complex medical needs. And, no surprise, nearly 9 out of 10 direct-care workers are women, 28 percent are African-American and 23 percent are immigrants [PDF].

These caregivers provide the most intimate care imaginable to frail and vulnerable people. We depend on them to give competent, compassionate attention to our grandparents—and to us as we age. Their clients’ lives are literally in their hands. “What we do is important,” says Tracy Dudzinski, a direct-care worker in Wisconsin since 1996. “One of the most rewarding experiences you can have is to go in and help make a difference in a person’s day.”

According to the Bureau of Labor Statistics Occupational Outlook Handbook, the elder care field is among the fastest-growing in the nation, with 50 percent growth from 2008 to 2018 predicted for home-care workers. But we’re doing little to attract people to these critical jobs. We reward women like Tracy with wages of less than $10 an hour. And Tracy, whose husband is on disability, is the sole breadwinner for her family of four children. Like another heavily-female occupation–child care–our nation expects caregivers to subsidize these services with their low wages.

Now, direct care workers are taking matters into their own hands and speaking out. “People misunderstand us,” says Tracy. “We’re smart people and hard workers.” Tracy has a leadership role in an emerging movement to transform the lives of direct care workers: She is a staffer at Cooperative Care, a worker-owned co-op of home-care workers based in Wautoma, Wisconsin. She also serves on the boards of both the Wisconsin Direct Care Allianceand the national Direct Care Alliance (DCA), headquartered in New York City. She has traveled to Capitol Hill and the Institute of Medicine of the National Academies to testify about the working conditions of her peers. “I used to be the mouse in the corner,” she says. “Now I’m a changed person.”

Among DCA’s most successful projects is the Voices Institute, a week-long retreat and intensive training session for direct-care workers to become advocates for their profession.

When I asked Tracy what the public can do to support these efforts, she offered, “Show direct-care workers some respect. Get involved with the DCA. Learn about the issues and contact legislators. The more noise we make, the sooner things will be fixed.”

Most Doctors Would Refuse a Feeding Tube For Themselves; Why Do They Place Them So Often?

Dr. Kirsch from MDWhistleblower has a new post on feeding tubes:

Last week, I was asked by a primary care physician to place a feeding tube in an NNHP, a nonagenarian nursing home patient. The patient had a panoply of active medical issues, and was at the end of life. The feeding tube was advised because the patient’s swallowing function was impaired and he was, therefore, at risk for pneumonia if he ate. These swallowing evaluations are generally performed by speech pathologists, whom I have found to be dedicated and competent professionals. As an aside, they often uncover swallowing defects that suggest that eating regular food may be unsafe, even though I suspect that these ‘defects’ were present for several years. Somehow, these patients ate regular food and survived.

As the patient was not capable of providing informed consent, I contacted the patient’s legal guardian, who is his grandson and a physician. While I was hoping that he would decline the tube and opt for comfort care, he was adamant that the tube be placed. I did so on the following day. Yesterday, a day after the tube was placed, he died, not from a complication of the procedure, but because he had reached the end of his life.

In 20 years, I’ve place over a hundred feeding tubes, primarily in elderly and demented individudals. In most of these cases, I serve as a technician. I am not consulted for my advice on whether a feeding tube is in a patient’s interest, but am asked to insert one after the decision has already been made. More than any other gastro procedure I perform, placing these tubes, called PEGs by physicians, is the most troubling. There is no question that gastroenterologists like me are placing more of these tubes than are medically necessary. Over the past few years, several medical papers have documented that providing tube nutrition for patients at the end of life, or with advanced dementia, provides no benefit. It does not prolong or improve life for many of these patients. Why, then, do we do it so often?

Read the entire post here.

GeriPal: What a Nursing Assistant Will Tell Us If We Ask.

From fantastic GeriPal, a note of the changing culture of health care deliver and the increase of home health care. This is a must read for those of us who are paying attention to how patients' rights and needs will have to be met in the coming new reorganization of health care for the terminal and elderly.

It is projected that there will be a 50% growth in home health aide positions in the next ten years because of the expansion of home care for our geriatric population (US Bureau of Labor Statistics). How will we work with home health aides to increase retention? How can we argue for better compensation for such a demanding (physically and emotionally) position? And for those of us involved ingeriatric palliative care, how can we ensure that palliative care education is offered and encouraged for home health aides?

In the larger picture, offering continuing education and acknowledging specialized training is a start. I know that programs such as ELNEC-Geriatric include specific content and attention to nursing assistants (self disclosure - I’m part of the team offering this course in Philadelphia in March-link above is for this, but see * below for more details). And in recognition of additional education and experience in palliative care, HPNA (through NBCHPN) offers certification for nursing assistants. These are a start—as was the public attention given to the role in the Washington Post articles. In my own practice, the same as with most of you I assume, I often elicit opinions and thoughts from the home health aides caring for an individual. But in the smaller, every day picture is this enough? How we can better include nursing assistants in palliative care teams? I don’t have the answer, but I do think that as we continue to consider how geriatric palliative care is delivered, we all need to advocate for nursing assistants as valued members of the interdisciplinary team.

Health Care Reform and Palliative Care.

Tim Cousounis at Palliative Care Success looks at the reasons why Palliative care, though cost saving and vital to good end of life care, is not likely to expand at a great rate any time soon:

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.

Opioid Use for Elder, Chronic Pain Relief.

Don't miss the fantastic discussions at Pallimed and GeriPal regarding the use of opioids for relief of pain in the elderly. Last week's study is dissected by the amazing commenters and you'll have a better understanding of the challenges faced when working to relieve pain.

Here's a clip from GeriPal's article to bring you up to speed:

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?

And here's the link to Pallimed. Don't miss the comments at either section.

Top 50 Hospice, Elder Care Blogs.

The Health Herald blog has done us a favor by listing their pick of the top 50 hospice and elder care blogs:

General Hospice Care Blogs

Get a general idea of what hospice care is all about, and learn more about your options and the possibilities.

1. Hospice Blog: This offers information on hospice care, and the fight for quality care.
2. Hospice Physician’s Blog: Learn about hospice and how it works from a doctor working in the field.
3. Hospice and Nursing Homes Blog: Hospice practices, insights, research, news and issues.
4. Hospice and Caregiving Blog: News, information and more surrounding hospice care, as well as information for caregivers.
5. Home Care Law Blog: This blog focuses on legal issues surrounding home hospice care.
6. Alive Hospice Blog: Learn more about hospice care and end of life issues from a hospice provider.
7. Hospice: Learn more about hospice care, and what goes into it, as well as what to expect.
8. Life as a Hospice Patient: This is an interesting firsthand account of a hospice patient, and what hospice care means to her.
9. Compton Hospice: Get a view of hospice care from a British perspective.

Elder Care Blogs

Find out about senior living, and how hospice care can fit into the picture. These blogs also include information about finding hospice care and making the most of it.

10. AARP: Read the blog from the AARP, including coverage of issues related to health care, hospice care and end of life.
11. Eldercare ABC Blog: Learn about the essentials of elder care, and find valuable resources and support.
12. Elder Care Diary: Keep up with the day to day activities of a family involved in elder care.
13. ElderCare Expert: Get useful insights and helpful hints from someone who has been involved in senior care for a long time.
14. The New Old Age: A look at the way we age in these modern times. An interesting look at hospice, assisted living and other related issues.
15. Senior Care Blog: Learn about issues associated with aging, as well as elder health, and information on long term home care.
16. Choosing Elder Care: A review of different options in elder care, and helpful information and resources.
17. Elder Care Blog: Learn about issues that come up in elder care, as well as issues relating to end of life.

Death Care Blogs

Get insight into the end of life process, and learn about how hospice care can fit into this.

18. Death Care Law Blog: Keep up with what your rights are in end of life, and find information about pre-need issues.
19. Death Care Law: Another interesting legal blog focusing on death issues.
20. How We Die: An interesting look at stories from people regarding death, and how we view death as a society.
21. Medical Futility Blog: Get a tongue in cheek look at the issues — judicial, legislative and political — surrounding the end of life.
22. The Good Death: Bringing about death with dignity, and a look at how society deals with death.
23. Death Care: Looks at issues surrounding death, as well as provides resources to help you make more informed decisions.

Pain Management Blogs

One of the important functions of hospice care is to provide pain management. Read about different options and treatments, as well as additional information on palliative care.

24. Palliative Care: This About.com blog focuses on pain management, as well as easing some of the other symptoms often associated with the approach of life’s end.
25. GeriPal: This blog focuses on palliative care and pain management in the elderly. Offers helpful posts and insight into different medicinal options.
26. Pallimed: A look at the role palliative care plays in the way hospice care handles end of life.
27. Palliative Care Success: Explores the successes seen in pain management and symptom control as part of hospice care.
28. Pain Management Blog: Focuses on different advances in pain management.
29. Chronic Pain Management: Learn how to deal with chronic pain, and help others deal with it.
30. St. Christopher’s Blog: Malcolm Payne: This blog is offered up by St. Christopher’s Hospice in London, and provides insight into palliative care and social care for end of life.
31. Palliative Care Bulletin: Get the latest news alerts about end of life care.

Nursing Home Blogs

While not exactly hospice care, nursing homes can provide many of the same services. Learn about different nursing home options and possibilities, as well as preparation for long-term care.

32. My Better Nursing Home: Get an idea of what better nursing home care could look like, and how we might be able to get there.
33. My Elder Advocate: This blog deals mostly with issues related to nursing homes, and your rights with regard to them.
34. The Nursing Home Administrator: Get an insider’s view of how a nursing home is run from a nursing home administrator in Indiana.
35. Jonathon Rosenfeld’s Nursing Homes Abuse Blog: This blog focuses on nursing home abuses, and shows you how you can get better care from your nursing home.
36. South Carolina Nursing Home Blog: News and information related to nursing homes, especially those in South Carolina.

Caregiver Blogs

Being a caregiver for someone approaching their end of life can be difficult. Learn about others’ experiences and find sources of strength and support.

37. Caregiver List: Helpful information on where to find information about different facilities, training and other items.
38. Inside Elder Care: Get a firsthand look at caring for others. This blog is written by someone who is caring for his aging mother.
39. Lasting Tribute: This isn’t just about the elderly. You can leave stories and messages about anyone who has died. But the blog includes plenty of interesting stories from caregivers and others.
40. Risa’s Pieces: Learn about what it’s like to be a hospice caregiver from this compassionate professional.
41. Caring for Aging Parents: Learn about how you can cope with caring for aging parents, and find support as well as answers to your questions.
42. Caregiver Support Blog: Find support in your position as caregiver, and read about others.
43. The Caregiver’s Blog: Learn about being a caregiver and find support from others in a similar position.
44. Caregiving: Tips and hints for caregivers, especially those who are caring for people with Alzheimer’s.

Nurse Blogs

Get professional insight from health care professionals who have some experience with end of life.

45. Dethmama Chronicles: Follow the adventures of this end of life nurse. Includes some funny insights and more.
46. Midwife for the End-of-Life: Get accounts of what it’s like to be a nurse caring for those who are near death.
47. code blog: This nurse shares her experience as an ICU nurse, as well as insights on end of life.
48. River of Life: Notes of a Hospice Nurse: This video offers a look into life as a hospice nurse.
49. A Hospice Nurse’s Story: This post on from the Center to Champion Nursing in America offers a poignant look at what it’s like to care for others in a hospice setting.
50. Minnesota HomeCare Association’s Nurse Consultant BLOG: Get an idea of what is going on in the world of home care nursing.

Frailty and the Elderly.

GeriPal looks at how we fail to prepare the elderly for the frailty that often comes at the end of life.

Paula Span raises a number of interesting issues in this post on the NY Times New Old Age Blog. She presents the story of an active 70 something man who was very comfortable discussing the possibility of his death, but seemingly unable to discuss the possibility of being frail and needing help caring for himself.


As the post notes, most people will have a period (often quite long) of frailty at the end of their lives in which they will need the help of another person for some tasks of daily living. I think the popular media and many in the medical profession sometimes try to suggest otherwise, suggesting that frailty is avoidable if you just do the right things. The evidence overwhelmingly suggests otherwise. It is certainly right to encourage good health habits, including good nutrition and exercise. But it is more likely that healthy living will delay frailty--not avoid it.


I think even in Geriatrics, we sometimes oversell our ability to prevent functional decline and frailty. In our enthusiasm, we point to some intervention studies that have reduced the risk of disability. These intervention can clearly enhance the well being of older persons, and it is a shame they are not more widely implemented. But if one looks closely at these studies, the effect sizes tend to be modest, and they slow down trajectories of decline rather than stop these trajectories.

Top 10 Geriatric Advancements of the Last Decade.

Dr. John Morley at stltoday.com (St. Louis) notes the big medical advancements in geriatrics:

While there is still a severe shortage of geriatricians, this has been a decade in which both the public and politicians have become more aware of the need for specialist physicians who focus on the care of older persons. Geriatricians tend to focus on the older person’s ability to function, rather than on specific disease processes. This tends to give them a different perspective on medical advances. Here are my top ten breakthroughs in geriatrics in the last decade:

1. Exercise and sarcopenia. This decade has dramatically increased the awareness of the need for regular exercise (at least three times a week) for older persons. It has become clear that resistance exercise is essential to allow older persons to maintain muscle mass and strength (Stop sarcopenia). Simple exercise has also been shown to prolong life e.g. regular stair climbing; decrease the chance of developing dementia and slowing functional decline and enhancing the mood in depressed people. In the case of persons who are falling, resistance exercise along with balance exercise decreases falls. Physical therapists are now aware that as older persons develop memory problems, they find it difficult to “walk and talk”. Special exercises have been developed to improve the person’s ability to do another task while walking. All older persons who are falling should have six weeks of home exercise therapy from a physical therapist. All persons should increase their Spontaneous Physical Fun (SPF) by parking far away from their destination and climbing stairs.

2.Recognition of FRAILTY: Geriatricians have become very aware that older persons pass through a state of frailty before they become disabled. Frail persons have a combination of weight loss, decreased strength or activity, fatigue and multiple minor illnesses. Emerging evidence suggests that aggressive treatment of frailty may prevent disability from occurring. Treatment includes resistance exercise, increased protein in the diet and perhaps anabolic steroids. Testosterone, together with a protein-calorie drink, decreases hospitalisation. Testosterone improves function in older men and women with heart failure. A new anabolic steroid developed by GTx in Memphis almost looks like “exercise in a pill”.

3. Dabigatran: This drug which works as well as warfarin for older persons who need their blood thining, does not require regular blood sampling to maintain appropriate levels. It may have less side effects as well. The disadvantage is it needs to be taken twice a day. However, for both patients and physicians this drug appears to be likely to greatly improve quality of life.

4. Vitamin D: It is now recognized that the majority of older persons have low blood levels of the sunshine vitamin. Increasing these levels decreases falls, improves function, decreases hip fracture and decreases the chance of dying. Vitamin D is truly the vitamin of the decade.

5. Delirium Intensive Care Units: Older persons with delirium have poor outcomes in hospital. The development of Delirium Units at St Louis University and Des Peres hospitals by my colleague, Dr Joseph Flaherty, has markedly improved outcomes. This along with other system improvements for older persons has lead to more pleasant and happier hospital stays for older people.

6. Stem Cells for the Heart: A number of studies have shown that umbilical stem cells decrease subsequent heart attacks and may reverse hear failure. Fish oil (DHA and EPA) appears to be the miracle drug for heart disease.

7.Alzheimer’s Disease: The recognition that exercise appears to be as effective as available drugs to treat dementia opens the way for the development of new drugs. A number of candidates are being developed including our one (an antisense to Amyloid Precursor Protein developed at the St Louis Veteran’s Administration). The new screening test for dementia and predementia developed at Saint Louis University and the VA represents an important step forward in the early identification of persons at risk for Alzheimer’s disease. This can be coupled with a new skin test being developed for Alzheimer’s disease.

8.Reducing use of therapeutic drugs in older persons: Drugs are over utilized in the United States both by patients and physicians. It is now being recognized that over treatment can be as bad as under treatment. The Cochrane collaboration found that most older people have their blood pressure over treated. Antipsychotic drugs which are often used to treat behavioral problems in older persons have been shown to increase the death rate. One of our medical students actually found that exercise done three times a week was highly effective at reducing the need for drugs for agitation. Geriatricians specialize in reducing drugs.

9. Recognizing the Role of the Caregiver: The wonderful work done by families, certified nurse aides and others, looking after older persons in need of help is being much more recognized. These persons are the true angels of health care and are totally under reimbursed. The importance of high quality support groups such as those run by the Alzheimer’s Association (www.alz.org or 1-800-272 3900) has been recognized.

10. Recognition of Palliative Care: Slowly physicians and patients are recognizing that appropriate palliative and hospice care can allow us to go “gentle into the good night”. The Veterans Administration has been a leader in developing superb end of life care. Studies have shown that withdrawal of care at the right time may not only improve quality of our last days but may even extend life. So I guess I should thank Mr Limbaugh and governor Palin for their ridiculous characterisation of “death panels” as it gave an opportunity for more rational comments on palliative care to appear in the mainstream media.

I invite those of you reading this to comment on what you see as the major advances of the last decade.