Alex Smith, MD

Do you know what your staff is saying about palliative care?

Physician

November 1, 2016

Do you know what the operator or person at the front desk is saying about palliative care? When people call, saying the want palliative care, how are they responding?

A study being presented in abstract form at the palliative care and oncology research symposium addresses this simple but critical question.

Researchers at Duke (Kathryn Hutchins, third-year medical student first author, Arif Kamal, oncopal researcher, senior author) cold called 40 major comprehensive cancer centers. They …

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We are morally scarring our future physicians

Alex Smith, MD

Education

November 6, 2015

Have you ever had that experience when you think what you’re doing is futile, and that thought goes through your mind:

“Why am I doing this?”

“I’m torturing him.”

“This feels wrong.”

For those of us that are physicians, think back to your internship and residency training. I think we can all remember at least one of these situations, if not more.

I remember being in the ICU as a third-year internal medicine resident, being sent …

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Let’s celebrate nurses by reining in patient satisfaction

Alex Smith, MD

Physician

May 22, 2015

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Let’s take a moment to consider what makes a terrific nurse.

First, by way of gathering information, let’s consider the health care industry’s present views on excellence in nursing. Let’s think about how this conception of excellence in nursing aligns with our own perspectives.

In a recent Atlantic article, titled “The Problem with Satisfied Patients,” Alexandra Robbins writes about the economic …

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Handshakes transmit germs: What are doctors to do?

Alex Smith, MD

Physician

September 22, 2014

In a study in the American Journal of Infection Control, researchers coated a gloved hand in E. coli. One person with the E. coli glove then they shook hands, high-fived, and fist bumped another person with a sterile glove. Transfer of E. coli to the sterile glove was measured.

Results:

highest transfer of bacteria: handshake
lowest transfer of bacteria: fist bump (high five was in the middle)
difference: fist bump less than 10% of …
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Hospice patients can use functional improvement too

Alex Smith, MD

Physician

July 27, 2014

One of the skilled nursing facilities I work with has a hospice unit. We occasionally have patients on the hospice unit who might benefit from physical therapy. The physical therapists that see patients in the skilled nursing facility say they will talk with the patient about their goals, and if their goals are to maintain their current level of functioning, they will work with the patient. If the goals are …

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When should you use antibiotics in hospice care?

Alex Smith, MD

Physician

January 23, 2014

Case 1: You have a 94-year-old woman with multiple medical problems in hospice who develops a fever (subjectively hot to the touch), shortness of breath, and a cough producing yellow sputum. Her daughter asks if she can be treated with antibiotics “to make her feel better.” The patient is not well enough to make decisions, but in earlier conversations had stated a goal of remaining comfortable at home, while also …

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Communication about prognosis and goals of care is still lacking

Alex Smith, MD

Conditions

October 14, 2013

Advanced dementia is a terminal illness needing palliative care. Unfortunately, there is a great divide between this statement of the world as it should be, and the current reality of the world as it is. Rates of pain and shortness of breath are high for patients with advance dementia. Patients with advanced dementia often reside in nursing homes, and few nursing homes offer specialized palliative care services.

And, as we can see from an …

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A natural death: What exactly does that mean?

Alex Smith, MD

Physician

June 11, 2013

What is a natural death, anyway?

I get it – death is part of the cycle of life. Seasons change. The moon waxes and wanes. We are born. We die. Death is natural.

But what is a “natural” death? Seriously, what comes to mind when you think of natural death? Here is a video of a natural death, taken from the Planet Earth series:

Death in nature is often violent, brutal, …

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Psychological factors influence how patients interpret information

Alex Smith, MD

Physician

July 10, 2012

Here is the setup. You’re working in the ICU. You want to communicate a prognosis to the family of a patient who is so ill he cannot make decisions. You sensitively state the facts: the patient has less than a 5% chance of survival. Or perhaps you say “he will definitely not survive.”

The family confers, and decides that they want to focus on keeping him alive as long as possible. …

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Alzheimer’s inevitably leads to loss of financial capacity

Alex Smith, MD

Conditions

August 14, 2011

“Mom’s been writing goofy checks…”
“Dad stopped paying his bills….”
“Grandma wired her savings to Nigeria…”

Have you heard these phrases from the family caregivers of your elderly patients? Have you ever been concerned that your patient may lack capacity for financial decision making? How do you decide if they lack capacity? What is the clinician’s role in making these decisions? What is their responsibility?

These important questions are addressed in a terrific new article in …

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Adults living with dementia and disability need research funding

Alex Smith, MD

Patient

August 23, 2010

I heard a prominent speaker talk about studies at the National Institute of Aging. The speaker described several new large and well funded trials aimed at preventing illnesses associated with aging, such as dementia and disability. These studies are terrific, and worthy of funding.

I was disappointed, however, that little was said about funding for studies of older adults already living with dementia and disability. Research in prevention will not help these patients. I asked: where is the …

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Nurses are underappreciated but key to patient care

Alex Smith, MD

Patient

June 24, 2010

“No man, not even a doctor, ever gives any other definition of what a nurse should be than this — ‘devoted and obedient.’ This definition would do just as well for a porter. It might even do for a horse. It would not do for a policeman.”

-Florence Nightingale, 1859

Please take a moment to celebrate the nurses in your life. Florence Nightingale was the first to publicly decry the sorry …

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Palliative care needs a simple and consistent message

Alex Smith, MD

Physician

April 20, 2010

I was consulted recently about an elderly woman who refused surgery for a large bowel obstruction from a colonic mass, likely cancer. The inpatient team asked me to help with the transition to hospice and to help make her comfortable.

I went to see her. She had a nasogastric tube sucking up brown material from her stomach. Her abdomen was swollen and uncomfortable. Her primary goal was to return to walking …

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The power of a doctor’s choice of words in explaining CPR

Alex Smith, MD

Conditions

February 8, 2010

Words have power. Language has power.

The words we use may comfort or shock, allay or provoke, sooth or batter. Words often imply layers of meaning that are not explicitly articulated, yet rest beneath the surface:

“I worry that time is short for you” (You are dying) (I care about you)

“I wish we could have done more” (Nothing would have changed her death) (I am on your side)

“I hope with you that …

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Learn how to conduct a family meeting by using a structured approach

Alex Smith, MD

Patient

November 16, 2009

On my last day of ward attending, I handed out an EKG that resembled the Dow Jones industrial average over the last 10 years (not pictured). The normal pattern of an EKG was completely disrupted: ST segments were markedly elevated, P waves were hidden, and beats were grouped in odd patterns. My medical team laughed and shook their heads.

I asked why.

A brave intern responded that he was completely at a …

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