#Palliative Care

[mostlysignssomeportents]

America's largest hospital chain has an algorithmic death panel

It’s not that conservatives aren’t sometimes right — it’s that even when they’re right, they’re highly selective about it. Take the hoary chestnut that “incentives matter,” trotted out to deny humane benefits to poor people on the grounds that “free money” makes people “workshy.”

There’s a whole body of conservative economic orthodoxy, Public Choice Theory, that concerns itself with the motives of callow, easily corrupted regulators, legislators and civil servants, and how they might be tempted to distort markets.

But the same people who obsess over our fallible public institutions are convinced that private institutions will never yield to temptation, because the fear of competition keeps temptation at bay. It’s this belief that leads the right to embrace monopolies as “efficient”: “A company’s dominance is evidence of its quality. Customers flock to it, and competitors fail to lure them away, therefore monopolies are the public’s best friend.”

But this only makes sense if you don’t understand how monopolies can prevent competitors. Think of Uber, lighting $31b of its investors’ cash on fire, losing 41 cents on every dollar it brought in, in a bid to drive out competitors and make public transit seem like a bad investment.

Or think of Big Tech, locking up whole swathes of your life inside their silos, so that changing mobile OSes means abandoning your iMessage contacts; or changing social media platforms means abandoning your friends, or blocking Google surveillance means losing your email address, or breaking up with Amazon means losing all your ebooks and audiobooks:

https://www.eff.org/deeplinks/2021/08/facebooks-secret-war-switching-costs

Businesspeople understand the risks of competition, which is why they seek to extinguish it. The harder it is for your customers to leave — because of a lack of competitors or because of lock-in — the worse you can treat them without risking their departure. This is the core of enshittification: a company that is neither disciplined by competition nor regulation can abuse its customers and suppliers over long timescales without losing either:

https://pluralistic.net/2023/01/21/potemkin-ai/#hey-guys

It’s not that public institutions can’t betray they public interest. It’s just that public institutions can be made democratically accountable, rather than financially accountable. When a company betrays you, you can only punish it by “voting with your wallet.” In that system, the people with the fattest wallets get the most votes.

When public institutions fail you, you can vote with your ballot. Admittedly, that doesn’t always work, but one of the major predictors of whether it will work is how big and concentrated the private sector is. Regulatory capture isn’t automatic: it’s what you get when companies are bigger than governments.

If you want small governments, in other words, you need small companies. Even if you think the only role for the state is in enforcing contracts, the state needs to be more powerful than the companies issuing those contracts. The bigger the companies are, the bigger the government has to be:

https://doctorow.medium.com/regulatory-capture-59b2013e2526

Companies can suborn the government to help them abuse the public, but whether public institutions can resist them is more a matter of how powerful those companies are than how fallible a public servant is. Our plutocratic, monopolized, unequal society is the worst of both worlds. Because companies are so big, they abuse us with impunity — and they are able to suborn the state to help them do it:

https://www.cambridge.org/core/journals/perspectives-on-politics/article/testing-theories-of-american-politics-elites-interest-groups-and-average-citizens/62327F513959D0A304D4893B382B992B

This is the dimension that’s so often missing from the discussion of why Americans pay more for healthcare to get worse outcomes from health-care workers who labor under worse conditions than their cousins abroad. Yes, the government can abet this, as when it lets privatizers into the Medicare system to loot it and maim its patients:

https://prospect.org/health/2023-08-01-patient-zero-tom-scully/

But the answer to this isn’t more privatization. Remember Sarah Palin’s scare-stories about how government health care would have “death panels” where unaccountable officials decided whether your life was worth saving?

https://pubmed.ncbi.nlm.nih.gov/26195604/

The reason “death panels” resounded so thoroughly — and stuck around through the years — is that we all understand, at some deep level, that health care will always be rationed. When you show up at the Emergency Room, they have to triage you. Even if you’re in unbearable agony, you might have to wait, and wait, and wait, because other people (even people who arrive after you do) have it worse.

In America, health care is mostly rationed based on your ability to pay. Emergency room triage is one of the only truly meritocratic institutions in the American health system, where your treatment is based on urgency, not cash. Of course, you can buy your way out of that too, with concierge doctors. And the ER system itself has been infested with Private Equity parasites:

https://pluralistic.net/2022/11/17/the-doctor-will-fleece-you-now/#pe-in-full-effect

Wealth-based health-care rationing is bad enough, but when it’s combined with the public purse, a bad system becomes a nightmare. Take hospice care: private equity funds have rolled up huge numbers of hospices across the USA and turned them into rigged — and lethal — games:

https://pluralistic.net/2023/04/26/death-panels/#what-the-heck-is-going-on-with-CMS

Medicare will pay a hospice $203-$1,462 to care for a dying person, amounting to $22.4b/year in public funds transfered to the private sector. Incentives matter: the less a hospice does for their patients, the more profits they reap. And the private hospice system is administered with the lightest of touches: at the $203/day level, a private hospice has no mandatory duties to their patients.

You can set up a California hospice for the price of a $3,000 filing fee (which is mostly optional, since it’s never checked). You will have a facility inspection, but don’t worry, there’s no followup to make sure you remediate any failing elements. And no one at the Centers for Medicare & Medicaid Services tracks complaints.

So PE-owned hospices pressure largely healthy people to go into “hospice care” — from home. Then they do nothing for them, including continuing whatever medical care they were depending on. After the patient generates $32,000 in billings for the PE company, they hit the cap and are “live discharged” and must go through a bureaucratic nightmare to re-establish their Medicare eligibility, because once you go into hospice, Medicare assumes you are dying and halts your care.

PE-owned hospices bribe doctors to refer patients to them. Sometimes, these sham hospices deliberately induce overdoses in their patients in a bid to make it look like they’re actually in the business of caring for the dying. Incentives matter:

https://www.newyorker.com/magazine/2022/12/05/how-hospice-became-a-for-profit-hustle

Now, hospice care — and its relative, palliative care — is a crucial part of any humane medical system. In his essential book, Being Mortal, Atul Gawande describes how end-of-life care that centers a dying person’s priorities can make death a dignified and even satisfying process for the patient and their loved ones:

https://atulgawande.com/book/being-mortal/

But that dignity comes from a patient-centered approach, not a profit-centered one. Doctors are required to put their patients’ interests first, and while they sometimes fail at this (everyone is fallible), the professionalization of medicine, through which doctors were held to ethical standards ahead of monetary considerations, proved remarkable durable.

Partly that was because doctors generally worked for themselves — or for other doctors. In most states, it is illegal for medical practices to be owned by non-MDs, and historically, only a small fraction of doctors worked for hospitals, subject to administration by businesspeople rather than medical professionals.

But that was radically altered by the entry of private equity into the medical system, with the attending waves of consolidation that saw local hospitals merged into massive national chains, and private practices scooped up and turned into profit-maximizers, not health-maximizers:

https://prospect.org/health/2023-08-02-qa-corporate-medicine-destroys-doctors/

Today, doctors are being proletarianized, joining the ranks of nurses, physicians’ assistants and other health workers. In 2012, 60% of practices were doctor-owned and only 5.6% of docs worked for hospitals. Today, that’s up by 1,000%, with 52.1% of docs working for hospitals, mostly giant corporate chains:

https://prospect.org/health/2023-08-04-when-mds-go-union/

The paperclip-maximizing, grandparent-devouring transhuman colony organism that calls itself a Private Equity fund is endlessly inventive in finding ways to increase its profits by harming the rest of us. It’s not just hospices — it’s also palliative care.

Writing for NBC News, Gretchen Morgenson describes how HCA Healthcare — the nation’s largest hospital chain — outsourced its death panels to IBM Watson, whose algorithmic determinations override MDs’ judgment to send patients to palliative care, withdrawing their care and leaving them to die:

https://www.nbcnews.com/health/health-care/doctors-say-hca-hospitals-push-patients-hospice-care-rcna81599

Incentives matter. When HCA hospitals send patients to die somewhere else to die, it jukes their stats, reducing the average length of stay for patients, a key metric used by HCA that has the twin benefits of making the hospital seem like a place where people get well quickly, while freeing up beds for more profitable patients.

Goodhart’s Law holds that “When a measure becomes a target, it ceases to be a good measure.” Give an MBA within HCA a metric (“get patients out of bed quicker”) and they will find a way to hit that metric (“send patients off to die somewhere else, even if their doctors think they could recover”):

https://en.wikipedia.org/wiki/Goodhart%27s_law

Incentives matter! Any corporate measure immediately becomes a target. Tell Warners to decrease costs, and they will turn around and declare the writers’ strike to be a $100m “cost savings,” despite the fact that this “savings” comes from ceasing production on the shows that will bring in all of next year’s revenue:

https://deadline.com/2023/08/warner-bros-discovery-david-zaslav-gunnar-wiedenfels-strikes-1235453950/

Incentivize a company to eat its seed-corn and it will chow down.

Only one of HCA’s doctors was willing to go on record about its death panels: Ghasan Tabel of Riverside Community Hospital (motto: “Above all else, we are committed to the care and improvement of human life”). Tabel sued Riverside after the hospital retaliated against him when he refused to follow the algorithm’s orders to send his patients for palliative care.

Tabel is the only doc on record willing to discuss this, but 26 other doctors talked to Morgenson on background about the practice, asking for anonymity out of fear of retaliation from the nation’s largest hospital chain, a “Wall Street darling” with $5.6b in earnings in 2022.

HCA already has a reputation as a slaughterhouse that puts profits before patients, with “severe understaffing”:

https://www.nbcnews.com/health/health-news/workers-us-hospital-giant-hca-say-puts-profits-patient-care-rcna64122

and rotting, undermaintained facililties:

https://www.nbcnews.com/health/health-care/roaches-operating-room-hca-hospital-florida-rcna69563

But while cutting staff and leaving hospitals to crumble are inarguable malpractice, the palliative care scam is harder to pin down. By using “AI” to decide when patients are beyond help, HCA can employ empiricism-washing, declaring the matter to be the factual — and unquestionable — conclusion of a mathematical process, not mere profit-seeking:

https://pluralistic.net/2023/07/26/dictators-dilemma/ggarbage-in-garbage-out-garbage-back-in

But this empirical facewash evaporates when confronted with whistleblower accounts of hospital administrators who have no medical credentials berating doctors for a “missed hospice opportunity” when a physician opts to keep a patient under their care despite the algorithm’s determination.

This is the true “AI Safety” risk. It’s not that a chatbot will become sentient and take over the world — it’s that the original artificial lifeform, the limited liability company, will use “AI” to accelerate its murderous shell-game until we can’t spot the trick:

https://pluralistic.net/2023/06/10/in-the-dumps-2/

The risk is real. A 2020 study in the Journal of Healthcare Management concluded that the cash incentives for shipping patients to palliatve care “may induce deceiving changes in mortality reporting in several high-volume hospital diagnoses”:

https://journals.lww.com/jhmonline/Fulltext/2020/04000/The_Association_of_Increasing_Hospice_Use_With.7.aspx

Incentives matter. In a private market, it’s always more profitable to deny care than to provide it, and any metric we bolt onto that system to prevent cheating will immediately become a target. For-profit healthcare is an oxymoron, a prelude to death panels that will kill you for a nickel.

Morgenson is an incisive commentator on for-profit looting. Her recent book These Are the Plunderers: How Private Equity Runs — and Wrecks — America (co-written with Joshua Rosner) is a must-read:

https://pluralistic.net/2023/06/02/plunderers/#farben

I’m kickstarting the audiobook for “The Internet Con: How To Seize the Means of Computation,” a Big Tech disassembly manual to disenshittify the web and bring back the old, good internet. It’s a DRM-free book, which means Audible won’t carry it, so this crowdfunder is essential. Back now to get the audio, Verso hardcover and ebook:

http://seizethemeansofcomputation.org

If you'd like an essay-formatted version of this thread to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2023/08/05/any-metric-becomes-a-target/#hca

[Image ID: An industrial meat-grinder. A sick man, propped up with pillows, is being carried up its conveyor towards its hopper. Ground meat comes out of the other end. It bears the logo of HCA healthcare. A pool of blood spreads out below it.]

Image: Seydelmann (modified) https://commons.wikimedia.org/wiki/File:GW300_1.jpg

CC BY 3.0 https://creativecommons.org/licenses/by-sa/3.0/deed.en

[somuchtostudysolittletime]

13/7/23 // 12.23

Study day for me today aka endless hot drinks and snacks

[cheerfullycatholic]

“[Euthanasia] is never a source of hope or genuine concern for the sick and dying. Instead, it is a failure of love, a reflection of a ‘throwaway culture’ in which ‘persons are no longer seen as a paramount value to be cared for and respected,'” he continued. “Indeed, euthanasia is often presented falsely as a form of compassion. Yet ‘compassion,’ a word that means ‘suffering with,’ does not involve the intentional ending of a life, but rather the willingness to share the burdens of those facing the end stages of our earthly pilgrimage. Palliative care, then, is a genuine form of compassion, for it responds to suffering, whether physical, emotional, psychological or spiritual, by affirming the fundamental and inviolable dignity of every person, especially the dying, and helping them to accept the inevitable moment of passage from this life to eternal life.”

[344x-azucar]

Commission of a scene from the fic Perfectly Imperfect by JustSomeStranger !

[pro-birth]

Friendly reminder that prenatal children with a terminal diagnosis have a right to hospice/palliative care, and parents have a right to obtain emotional and psychological support through that time.

[bexybat456]

Just seen a woman on TV protesting against euthanasia for disabled people, her argument being "well I'm disabled and I don't want to be euthanized!!"

I just wanted to scream. Disabled or not, this isn't about you. This is about terminally ill people desperately wanting dignity in death! People like you are inhibiting perhaps the most death positive movement England has ever passed for selfish, unfounded, unsympathetic reasons.

People are more or less acquainted with the "my body my choice" argument following the recent rows over abortion, so why can't that be applied to dying people desperate to retain the dignity stripped of them by their sickness.

[wellsbering]

i generally don't post about my personal life on here, but i went to high school with ariel and watching her cystic fibrosis progress so rapidly in recent years has been devastating. she's entering hospice today and is raising money to pay for her care, as her insurance won't cover all of her medical bills and as we all know healthcare in the united states is unbelievably expensive.

please donate if you're able, and please reblog this so it can reach other people.

[masterofescapism]

I’ve been dying for so long now that I’ve become used to it, but signing the DNR (do not resuscitate order) and starting palliative care has been eye opening.

Being online is so difficult now. EVERYONE talks about the future. Things they look forward to, things they want to change, saying that things will change. Will get better.

I even find myself thinking about books, movies, and tv shows, new seasons of the shows that’ll come out and that I don’t even know if I’ll be alive to see any of them.

It’s just really depressing and really hard knowing that things will not get better for me. It’s only going to get worse from here. But the world just spins madly on.

[importantwomensbirthdays]

Sharon Carstairs

Sharon Carstairs was born in 1942 in Halifax, Nova Scotia. In 1984, Carstairs was appointed leader of the Liberal Party in Manitoba, making her the first woman in the province's history to lead a major political party. In 1994, Carstairs was appointed to the Senate of Canada. From 2001 to 2003, she was Leader of the Government in the Senate and Minister with Special Responsibility for Palliative Care. Carstairs used this role to direct government money to programs and research in palliative care. She secured the funding to create the Canadian Virtual Hospice, an educational website with resources on loss, advanced illness, and palliative care. The site reaches millions in Canada and around the world. In 2016, Carstairs was appointed to the Order of Canada for her work championing palliative care.

[somuchtostudysolittletime]

14/4/24 // 15.58

Hello. I’m drowning in reflections to write up but exciting news!!!! I got offered a hospice job last week! I’m now a lead pharmacist for palliative care. What an absolutely exciting amazing moment in my life. Not at all where I thought my career would go but I absolutely cannot wait!

[cheerfullycatholic]

In an interview with Vatican News ahead of the event, Bishop Simard noted the confusion around palliative care, where euthanasia is permitted under the euphemism “medical assistance in dying,” or MAID. The practice involves doctors or nurse practitioners to either administer drugs to end a patient’s life, or provide drugs that are administered by the patients themselves.  Palliative care, by contrast, “is accompanying people’s lives,” said Bishop Simard, attempting to respond to all the person’s need. “So yes, we need to answer the problem of suffering and pain,” the Bishop says, “but at the same time, there are many other needs” that must be addressed.  ... “We are telling them: ‘You are still a person loved by God. You have your place in society. And we are here to tell you that we love you,’” the Bishop said.  It also means assuring them that they are not alone and expressing to them the compassion and tenderness of God that never leaves them.  Bishop Simard likewise highlighted the importance of listening to the person, “to her fears, to her anxiety, and also to what she is unable to say... accompanying helps them to express” their hopes and fears as they approach the end of their lives.  Palliative care, he continued, is also concerned for family members and other caregivers, for whom accompaniment can be a challenge. “We have to be there to listen to them and maybe offer them some respite,” he said, adding that listening to all those involved in palliative care is “essential.” The Canadian Bishop also emphasized the necessity of accompaniment in the dying person’s spiritual life. Prayer and the reception of the Sacraments are important means to help the person prepare themselves “to go and join the Lord in glory,” reflecting the “very important role” of palliative care for the spiritual life. 

[apenitentialprayer]

article by Sunita Puri, published October 5th, 2024. Bolded emphases added.

The first person who taught me something about death and defiance was the mother of a family friend, an older woman who had moved from Punjab to the United States to be closer to her son. I remember her as delicate and draped always in pastel salwar kameezes. After she was diagnosed with breast cancer, which moved quickly to claim her bones and her brain, her desire to return to Punjab intensified. When my parents told me about the end of her life, it was with a mixture of disbelief and conviction: She survived the days-long journey to the village where she’d been born—laboring to breathe for nearly the entire flight, grimacing through prayers when she ran out of pain medication—and died two days after she arrived.

I thought of her story this week as I read about former President Jimmy Carter’s intention to live long enough to vote for Kamala Harris. Carter, who has been on hospice for well over a year, turned 100 on Tuesday and has survived far longer than many expected he would. The notion that he has rallied in order to contribute in one final way to American democracy raises a familiar question that arises in my own work with patients and families: Do we have some control, conscious or not, over when we die? Can a person stretch the days of their life to include a last meaningful act or moment?

As a palliative-care physician, I have encountered the phenomenon of people dying only after specific circumstances materialize. There was the gentleman whose family held vigil in the intensive-care unit while he continued on, improbably, even without the support of the ventilator, dying only after his estranged son had arrived. There was the woman whose fragility precluded any further chemotherapy, but who survived long enough without it to witness the birth of her first grandchild. There was the woman who was deeply protective of her daughter, and died from cirrhosis only after she’d left for the night, possibly to spare her the agony of witnessing her death. The unexpected happens frequently enough that I tell patients and families that two timelines shape the moment of death: the timeline of the body, governed by the more predictable laws of physiology, and that of the soul, which may determine the moment of death in a way that defies medical understanding and human expectations. When people wonder about the circumstance of the last heartbeat, of the final breath, I can see how they never stop searching for their loved ones’ personhood or intention, a last gesture that reveals or solidifies who that person is.

Despite the prevalence of stories suggesting that people may have the ability to time their death, no scientific evidence supports this observation. Decades ago, several studies documented a dip in deaths just before Jewish holidays, with a corresponding rise immediately afterward, suggesting that perhaps people could choose to die after one final holiday celebration. A larger study later found that certain holidays (Christmas and Thanksgiving, in this case) and personally meaningful days (birthdays) had no significant effect on patterns of dying. But this phenomenon doesn’t lend itself easily to statistical analysis, either: The importance of holidays, for instance, can’t quite stand in for the very individual motivations that define the anecdotes shared in hospital break rooms or around a dinner table. And the human truth that many recognize in these stories raises the question of whether we believe them any less fully in the absence of proof.

Palliative care often involves helping people confront and develop a relationship to uncertainty, which governs so much of the experience of illness. And when my patients tell me about themselves and about who they are now that they are sick, willpower often makes an appearance. Many say that if they focus on the positive, or visualize the disappearance of their cancer, or fight hard enough, they will win the battle for more time. I hear in their words echoes of what Nietzsche wrote, what the psychiatrist Viktor Frankl used to make sense of his years in German concentration camps: “He who has a why to live for can bear almost any how.”

And we want to believe that love or desire or commitment or heroism is still possible right up until the very end. As my patients grow sicker, and as death approaches, I talk with them and their families about what they can hope for even if a cure isn’t possible. That, in fact, death can still contain something generative. A time that may have seemed beyond further meaning becomes instead an opportunity, or an extension of the dying person’s commitments to their country, their family, their dreams. Soon, President Carter will be able to cast that vote: Next week, Georgia registrars will start mailing out absentee ballots; early voting begins the week after that. His promise to himself is a reminder that dying cannot fully dampen purpose, even as a person’s life narrows.

The idea that willpower can be an ally against death is appealing too, because it offers the possibility of transcendence, of defying the limits that the body, or illness, may impose. But, having also seen the many ways that the body does not bend to the mind, I do find myself regarding willpower with caution: What if you as a person are a fighter, but your body simply cannot fight the cancer any longer? I wonder, with my patients, if they can strive for more time without shouldering personal responsibility for the limits of biology. Similarly, two people on ventilators may love their families equally. One may die only after the final beloved family member arrives, whereas the other may die before the person rushing across the ocean makes it home. We don’t always know why. If Carter casts his vote and dies shortly thereafter, that might affirm the notion that others, too, can write the final sentence in their story. But what would it mean if Carter died before casting his vote? If he lived another year, or if he lived to see Donald Trump take office again, or watch the election be violently contested? Living with loss requires remembering that we can locate the person we have loved or admired in any given set of events that comprised their life, not just the last one.

I try to imagine my family friend’s long flight from Los Angeles to Delhi, and her ride in the taxi back to Punjab. I think about how she found a way to endure what she was told she couldn’t, all to feel beneath her feet the soil she knew best, to die in the one place that she felt belonged to her. What if her doctors had been right and she had died on the plane? My family might have mourned her single-mindedness, or we might have admired her defiance nonetheless. What makes these stories so compelling is that they remind us that death, however ravenous, cannot devour hope or possibility, even if what transpires is not the ending we imagined.

[tilliwriteapine]

Okay! Now it's your turn! Tell me about your DNP project (or any of your dream projects) that you could share at a conference

Loadedddd question, haha!

I technically don't have to land on a project until this coming Spring term (April 2025), but I have been thinking about it. Since my DNP is associated with also becoming an NP, our instructors would like us to focus on how to implement things on the provider side of things versus nursing (though I think that is a bit unfair, considering the majority of my knowledge is nursing, and I'm also here to improve patient lives and outcomes, not just the provider process... but ya know).

So far my ideas include the process of implementing and managing blood glucose in stem cell transplant patients who have acute/chronic graft versus host disease, are in the inpatient setting, and are on high-dose steroids. Steroid-induced DM, or just exacerbate someone's DM! Right now, it is pretty well known that we are okay with blood glucose levels below 180 (typically between 140-180 is tolerated), but steroids make life a lot more tricky, especially when these patients can be on these steroids for *months*. I'm hoping I get to do a rotation on the transplant unit to find out their process (since I don't currently work there). This one is directly tied to how providers order and institute blood glucose management (insulin, sliding scales, etc), and I believe we can always do better when it comes to managing blood glucose.

My second idea (that likely has NO literature on it whatsoever, so it is unlikely to be a process I get to change any time soon, plus it is directly tied to nursing medication administration and not the provider side of medicine) is how we administer Daratumumab (a monoclonal antibody for multiple myeloma). It is frequently given as a subcutaneous injection these days (IV formulation still available), and it is 15 mLs over 5 minutes into the stomach once a week for about 8 weeks, then every two weeks for another 8 weeks, and then once a month until progression of disease. In this case, as someone who has given this drug hundreds of times at two different institutions, I wanted to see if I could implement a new quality improvement on how the drug is administered (a straight needle versus a butterfly needle).

Anecdotally, I have heard from nurses and patients that the butterfly needle is typically preferred. Some patients reported decreased discomfort with the butterfly needle, both during administration and hours after, and others didn't even notice. If you push the med too fast (15 mLs is a lot at once!), there can be discomfort. As for the nurses, we have better control over the syringe and have better ergonomics with a butterfly needle. When using a straight needle, you are holding the needle and syringe up against the skin and are leaning over the patient, which can be uncomfortable for the back and shoulders. You have the ability to sit back more and have more steady control over pushing the syringe when utilizing the butterfly needle. (We typically taped the butterfly needle down, which I think also decreases unnecessary needle movement). At least from what I have seen, there is no standard across the board for administration (just subcutaneous into the abdominal area).

I would love to compile some data on patient and nursing feedback on both administration techniques to get the ball rolling (but it sounds more research-based than quality improvement, and I guess I kind of disagree, but my instructors would argue with me... especially after this summer term. However, it is nursing-focused, not provider-focused, and there is unlikely to be any literature (multiple myeloma is a very small subset of blood cancer, and I pigeon-holed myself on data during my first research course in this program. I ran with it, but it was slim evidence to work with, and it was just around multiple myeloma and stem cell transplantation. I doubt anyone has even considered nursing preference in administration technique for one specific immunotherapy drug *laughs*). I'll get to this one day! Unfortunately, while I talked about it a lot with my fellow nurses in both Denver and here in Portland, I never had a way to implement a change or gather data (though before I left Denver, we changed from the straight technique to the butterfly needle. No idea what data was behind it, but the pharmacy drew up the drug and provided it with the butterfly needle. Daratumumab isn't hazardous, so my Portland job just gave us the bottle, lol)

I am also interested in palliative care (though that might be a project too big to chew for the size we have to limit ourselves to. My mentor Patti literally did her project on the barriers to mass transfusion protocol documentation. All she did was obtain qualitative data from the trauma ICU nurses voluntarily). Our mock project for our quality improvement course this summer was on palliative care in heart failure, and I know my classmate wants to take that and run with it. I also am far more interested in palliative care in oncology. But I couldn't say what I would want to do for a project other than something in palliative care and oncology.

Our instructors (and the class ahead of us, haha) would also love it if we took a previous project and continued it, but none of the current third years have a project I want to continue (no oncology!). I don't want to do a project I am not invested in or interested in.

I may come up with other ideas once we get further into our management courses and start clinicals in February (kajsdlkfjklajsdfl), but I am pretty passionate about DM treatment/management, stem cell transplants, oncology, and palliative care.

(I almost signed up for the elective about submitting abstracts and posters, but I chickened out and went with Institutional Racism. As I said, I have lowered my expectations, lmao. It has been a weird year. I have met some very impressive nursing greats - I effing met the creator of the Tanner's Model of Clinical Judgement. Mind. Blown!)

[nerdgirlnarrates]

Recently I was talking to another med student and shared that before my grandmother died, her heart failure had gotten so bad that her doctors couldn’t effectively diurese her and she ended up needing several thoracenteses. The other med student suggested that these procedures were too aggressive and my grandmother’s doctors should have let her die instead. And I’m confused, because these procedures were very much palliative in nature: it is painful to have a pleural effusion preventing you from breathing well. She needed surgery to address the valve issues causing her heart failure, but she was not a good candidate for surgery, so she had already foregone curative measures. Also, my grandmother did not want to die of a pleural effusion. I’m not saying her quality of life was good--it wasn’t--but she didn’t want to essentially drown to death. And I’m kind of upset at the notion that her doctors should have forced her to die that way. That’s not humanity, peace, or dignity in death. Maybe I’m misunderstanding something, but the conversation has left me unhappy.

[pro-birth]

This is what pro-life, palliative care looks like for the child with a terminal diagnosis.

[therapeuticmonologues]

My task is not to save the world, my task is to love it (as it dies)