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Wednesday, July 20, 2016
(This is the third of four posts by Drew on the language we use in hospice and palliative care. You may want to read his reflection on 10 years of practice or his other posts on euphemisms - "Comfort Care," and "Compassionate Extubation." - Ed.)
"Palliative Sedation." Golly I hate this one.
Frankly 'terminal sedation' was better, because it was at least less confusing, but neither of them are clear or transparent, and particularly 'palliative sedation' is just so confusing and potentially laden with too many meanings to be ever useful. There are so many clinical scenarios out there in which someone is sedated (deliberately, or as an aftereffect of trying to control pain/anxiety/dyspnea/etc; deeply or lightly; continuously until death vs temporarily as respite) in circumstances that the average person would agree would be 'palliative' or 'of-palliative-intent' that the term is useless.
There have been some people in the literature who call it some variation of 'deep, continuous sedation,' which I like a lot better, because it's a basically accurate description of the practice, at least the practice which is meant most of the time by 'palliative sedation' but not all the time, which sometimes gets contrasted with the 'proportionate palliative sedation' moniker, because there are so many different types of sedation-which-is-palliative, and OH MY GOD, right?
If we have a term which needs so much parsing, we need a different term.
If the thing you are talking about is deliberately inducing a state of unconsciousness, and keeping a patient in that state until they die, as a means of controlling otherwise uncontrollable symptoms in a dying patient, 'deliberate, deep, continuous sedation in a dying patient' seems about as accurate and parsimonious as you could get. There are people who propose this sort of sedation as a temporary measure, which I've never done, but you could then say 'deliberate, deep, respite sedation for severe symptoms' or some variation. If what you actually mean is aggressively managing symptoms with drugs even if some level of sedation is the consequence, then just say that, and not the reactionary, befuddled 'proportionate palliative sedation' monstrostiy.
Besides the ridiculously confusing nature of the phrase 'palliative sedation,' it's another example of the myriad ways in which 'palliative' is used: care-which-is-palliative, care-which-is-given-by-a-palliative-care-team, palliative pediatric cardiac surgeries, palliative chemo, used synonymously with 'comfort care', 'going palliative' etc etc. It just makes it worse for us to have the term pegged to this practice which, strictly defined, seems to happen very rarely in the US (deliberate, deep, continuous sedation), and reinforces an image of our care teams as people who just drug the hell out of patients. I once met a hospitalist who shook my hand and said to me kind of as an aside 'You know, I'm very pro-palliative sedation," as if he expected me to make eye contact and nod, in some sort of manly acknowledgement that I understood how forward thinking and progressive you are, what a friend to palliative care you'll be.
In all honesty, I thought to myself "OMG you are an idiot and I don't like you and I bet you're not comfortable with your patients' existential pain." Turns out, first impressions really are accurate, but that's another story.
Drew Rosielle, MD is a palliative care physician at University of Minnesota Health in Minnesota. He founded Pallimed in 2005. For more Pallimed posts by Drew click here.
Illustration Credit: Christian Sinclair CC-BY-SA-NC
Wednesday, July 20, 2016 by Drew Rosielle MD ·
Sunday, July 17, 2016
by John Florian
I am a hospice chaplain working in Central Ohio and am asked in that role to provide a prayer at the beginning of our interdisciplinary team meetings. I want the prayer to be truly interfaith and non-denominational, but even more importantly, I want the prayer to meet the team where it is in the moment, and to inspire them in their work. I use a mindfulness bell to set the tone for the prayer and to create a space in the day.
Here is a prayer I created for our team:
(mindfulness bell)
Let's take a deep breath . . . and find our spiritual center (pause)
May God bless our ministry today.
We call to mind the patients and families we are privileged to serve, and hold them in our hearts (pause)
Inspire us to be instruments of Your Compassion, offering genuine presence, comfort and hope to those we meet.
Since we often feel overwhelmed, help us take care of each other, and remember to take care of ourselves as well.
Help us to be patient with one another, and with ourselves, and when recognizing a Moment of Grace, to smile in appreciation.
May God bless our ministry today, and always.
Editor's note: John has graciously given permission for other hospice and palliative care teams to use this opening prayer for noncommercial purposes. If you do use it, please let us know what you think. If you have other suggestions for how you open your meetings that you would like to share with the Pallimed.org community, please email firstname.lastname@example.com
Photo Copyright: Deniz Altindas https://unsplash.com/@omeganova
Sunday, July 17, 2016 by Lizzy Miles ·
Wednesday, July 13, 2016
(This is the second of four posts by Drew on the language we use in hospice and palliative care. You may want to read his reflection on 10 years of practice or his first post on euphemisms - "Comfort Care." - Ed.)
Euphemistic phrase #2 that I'd like to never hear again: "Compassionate extubation."
By which people typically mean 'extubating someone who is on invasive mechanical ventilation who is not expected to survive long, to a plan of care that focuses on symptom alleviation.'
What bugs me about it is the use of the term 'compassionate' to try to encompass the idea of a dying patient, care goals focused on symptom alleviation and providing a comfortable death, etc. One could totally lack any compassion for a patient and agree to extubate them expecting them to die, based on a purely legalistic interpretation of contemporary medical ethics (patients have a right to say No, etc), and proceed to 'compassionately extubate' the patient, right? Compassion needn't enter into it.
I also dislike, and I have to admit this is a really visceral thing for me, the claiming of the mantle of 'compassion' for things we do in palliative care. It can imply that other things in medicine aren't compassionate, or are less so than us pallatieurs. Is the ED doctor who diagnoses your mother with severe hypoxemic respiratory failure from community acquired pneumonia and intubates her in the emergency department in order to save her life lacking in compassion? Is the critical care team who cares for a patient through ARDS into recovery, and extubates the patient to a facemask and ongoing aggressive management to, you know, save their life, lacking in compassion when they do that? Why do we need to add valorizing, morally-laden language to this act when we do it? Why not just 'discontinuing mechanical ventilation with a plan to keep a patient comfortable as they die?' or some such variation. I know, I know, it's too much of a mouthful, but if you don't object to 'comfort measures only' as discussed in Part 1, you could say "Discontinuing mechanical ventilation to a CMO plan of care' etc.
There are also variations 'palliative extubation,' or, god-save-us-all 'palliative liberation from the ventilator' etc.
(See the discussion on 'palliative sedation' in part 3 for why I don't like using 'palliative' in these contexts. In short, we do a lot of things in palliative care, and I don't see how it clarifies anything or helps anyone to associate our name which is already used in a bajillion different ways to this practice.)
What I dislike about 'liberation' is that is it unnecessarily moralistic. Why even introduce such a judgement? This is a technology which saves countless lives every year, not something to be 'liberated' from. If someone is receiving mechanical ventilation and it becomes apparent that it is not going to help them survive, or be a bridge to an acceptable recovery, or otherwise is against the patient's wishes/values, then we stop it, and provide appropriate ongoing medical care. Let's just say that, not that we are heroically 'liberating' patients. That's how it reads to me, as unnecessarily heroic.
I know some, patiens/families view it as a liberation and that's fine, that's a good thing, but that doesn't mean we should routinely call this event a liberation. Some patients quite happily call it 'pulling the plug' which doesn't mean I'm about to call it taht. Imagine the family who is agreeing to the vent being stopped but remain ambivalent, conflicted, worried are they doing the right thing, the moral thing, the loving thing and a doctor blithely walk in and start talking about doing this thing which will lead to their loved one dying quickly and you don't want them to die but in your heart know it's time and you've got to let this happen but it's so tough and the doctor starts calling it a 'liberation.' I'd be like W-T-F?? if I was that family member.
There's also the phrase 'terminal extubation.' I don't use it, but it bugs me less than 'compassionate' or 'palliative' extubation, because I think it's less euphemistic. However it's still not clear, not precise, could be interpreted many ways, so not so helpful. 'Discontinuing mechanical ventilation' is just fine.
Drew Rosielle, MD is a palliative care physician at University of Minnesota Health in Minnesota. He founded Pallimed in 2005. For more Pallimed posts by Drew click here.
Illustration Credit: Christian Sinclair CC-BY-SA-NC
Wednesday, July 13, 2016 by Drew Rosielle MD ·
Tuesday, July 12, 2016
by Christian Sinclair
Congrats to all of the 200+ new attending hospice and palliative medicine (HPM) physicians who completed fellowship at the end of June. We've already compiled advice on how to be the best physician you can be, but now you are probably starting to think about passing the HPM boards come November 7th, 2016*. (Same goes for those fellows who finished in 2015, since the board exam is on a two-year cycle.)
You will find some good information on the American Academy of Hospice and Palliative Medicine (AAHPM) subspecialty certification page. But beyond knowing the blueprint and areas covered by the exam, what you can you tangibly do to help ensure you pass the boards?
First, go back to your fellowship. Talk to your faculty and mentors about their own experience if you have not already. Review the talks and educational opportunities you had during your fellowship. You have good, free accessible educational materials, so use them.
Second, make the most use of the free stuff out there! In 2012, Pallimed and Geripal writers** got together to make board prep questions based on articles covered by the two blogs. If you do not have your copies of Blogs to Boards, then get them here now! The first PDF has just the questions so you are not tempted to peek. The second PDF has the questions with fully referenced answers and explanations so you can understand the concepts better. If you are a fellowship and want to use these questions, please go ahead, they are open access. Share, share, share. Just a bit of caution, these questions are four years old, and we have not revised it, so if you find anything out of sorts, please let us know. But, hey it is free and written by "well-respected" bloggers, so it's got that going for it, which is nice.
If you have time and some new attending money to spend, then you have a lot of options. The AAHPM Intensive Board Review Course is in two weeks. They have great faculty lined up and you will likely pick up some things you didn't necessarily catch in fellowship. I'll be there in Pittsburgh attending some of the other Summer Institute offerings, so if you are going stop me and say hello! Other board review courses are being offered by MD Anderson (I'll be there too, teaching this time!) and Mt. Sinai both in September. I don't know of any on the West Coast.
If your travel is all locked up because of your new job, then you may be interested in the newly released (this week!) HPM PASS 3rd edition. I have done both previous editions of HPM PASS, and will be getting the third edition soon. There are 150 questions so as a member it is a little over $1 per question which is a steal considering how freakin' hard it is to write good questions (See Blogs to Boards above).
Some other good tips:
- Review the archives of PC-FACS (available in the Journal of Pain and Symptom Management and through AAHPM)
- Review FAST FACTS available from the Palliative Care Network of Wisconsin (PC-NOW) - How many should you review? At least the 50 Essential Fast Facts, but hey you have several weeks so devour as many as you can.
- While you are at PC-NOW, check out the Fast Fact Quiz (and archives) - More free questions!
- Read the UNIPAC series, especially the book on Hospice to make sure you get your Medicare Hospice basics down. Sometimes these important issues can get lost in fellowship training.
Any of the nearly 7,000 board certified HPM physicians have any other good resources and tips? Share them in the comments below.
*Allopathic boards test date. The 2016 CAQ for DOs dates are not readily available. Does anyone know when they are?
**Makowski, Tatum, Rosielle, Widera, Sinclair
Christian Sinclair, MD, FAAHPM is a board-certified hospice and palliative medicine physician at the University of Kansas. If anyone wants to do something new with Blogs to Boards, he is all ears! Full disclosure, he is the current President of AAHPM, but he does not get a cut of any of the AAHPM items he is recommending above. They are truly great options. Just wanted to be clear. Also, I have nothing to do with the Board test questions (and neither does AAHPM by the way).
Illustration Credit: Christian Sinclair, original image from Caddyshack
Tuesday, July 12, 2016 by Christian Sinclair ·
Monday, July 11, 2016
JAMA Got It Wrong: Giving Prognostic Information to Families of Critically Ill Patients Is Not the Same as Palliative Care
I know I am not alone in my disappointment this week with the authors' conclusions in "Effect of Palliative Care-Led Meetings for Families of Patients with Critical Illness: A Randomized Clinical Trial." The study intervention involved the provision of an informational brochure and two focused meetings specifically designed to provide families with information about prognosis. The study found no difference in most outcomes between usual care and the intervention, and PTSD symptoms were in fact increased in the intervention group. The authors concluded that "these findings do not support routine or mandatory palliative care–led discussion of goals of care for all families of patients with chronic critical illness." What? How does this very specific, targeted intervention that deviates dramatically from usual palliative care practice become equated with palliative care?
As a palliative care physician at Mount Sinai, I participated in this study. I am not surprised by the negative results. These family meetings were highly scripted, designed to provide information about prognosis, and rarely involved the primary team. The study had great potential to make a contribution to the practice of critical care medicine, specifically to answer the question of whether offering prognostic information earlier in the critical illness trajectory could benefit patients and families. However, the study was designed such that the informers were not the patients' treating physicians. In fact, ICU team physicians participated in only 3-8% of meetings. Palliative care providers were chosen to given the information because of their expertise in communication. And yet nothing about the intervention resembled a standard palliative care intervention, which would have involved the entire IDT, multiple meetings for relationship building, information provided only when welcomed by the family, and the 100% presence of the ICU treating team at the meetings.
I remember back to one particularly distressing family meeting spent managing a family member's anger at what to them was shocking, new information about prognosis provided in the study brochure. This family was not ready to receive information about prognosis, especially without their primary team present. This is not standard palliative care. Again, I believe this study was bold and important in testing a specific information-giving intervention for a vulnerable patient population at high risk for unwanted overtreatment and suffering. It is the study's conclusions that are flawed, and I worry about their potential for depriving critically ill patients and their families from the benefits of true gold standard palliative care.
Elizabeth Lindenberger, MD, is a palliative care physician and program director for the Hospice and Palliative Medicine Fellowship at the Icahn School of Medicine at Mount Sinai in New York. This is her first Pallimed post.
(For more opinion on this JAMA article please see Alex Smith's post at Geripal - Ed.)
Photo Credit: @ismaelnieto
Monday, July 11, 2016 by Pallimed Editor ·
Friday, July 8, 2016
In this digital age, it is common to hear how devices isolate us from real authentic relationships. There are books written about how no one gets together once a week at the bowling alley or the coffee house, to just talk with friends and build that valuable relationship glue. I chuckle when I hear these concerns, because what I have experienced has been quite the opposite with the weekly #hpm chat on Twitter.*
(If you just saw the hashtag or the word Twitter and you immediately thought "I don't do Twitter," stick with me until the end!)
Next Thursday marks the 6th anniversary of #hpm chat, our weekly online chat dedicated to hospice and palliative medicine/care. In these six years, multiple friendships and connections have been made because of #hpm chat. Through these weekly conversations, I know social workers, physicians, pharmacists, chaplains, advocates and physicians I would never have likely met otherwise. They help inform my worldview of the field through sharing their experiences. One chatter recently mentioned that #hpm chat was like her interdisciplinary self-care. I must agree,. Each time I feel a little drained by work and think about skipping out on the Wednesday night chat, I sign on and find that I am re-energized by the end of the hour.
So I would like to invite you to come celebrate with us on our 6th anniversary.
For those of you who have never participated, if you have a Twitter account, please come join us. Just once and you will find a welcoming community that you'll want to come back to. If you do not have a Twitter account, you can always follow as a voyeur by following the #hpm hashtag before you decide to get a Twitter account (I realize it is not for everyone!)
If you only have used Twitter to follow the The Hospice and Palliative Care Annual Assembly, you will find the same energy and great info all year long each Wednesday night. If it invades family time, I get that, but think of it like going out after work with colleagues. You are entitled to do that a few times a year! It's good for your professional networking!
And if you are one of the thousands who have participated over the past six years, thank you so much for being part of a unique endeavor. Collectively we have made a tent pole for hospice and palliative care advocates to gather and support each other, all while being open to the public for education and feedback.
Since 2010 we have held 297 chats covering lots of topics, with a few repeats in there because the audience is always changing and people have new things to bring to the table. Since 2014 we have had 124 chats with nearly 88 million potential impressions from nearly 40,000 tweets from over 4,000 (non-unique) participants. We are excited to see what the future brings.
A big shout-out to the #hpm chat co-moderators: Meredith MacMartin (@GraniteDoc), Niamh van Meines (@EOLNavigator) and Ashley Deringer (@acderinger). They have done a great job making sure this chat functions week in and week out. If you are interested in helping with #hpm chat we have some projects we would like to do but need more volunteer hands on deck. Just contact any of us on Twitter or @hpmchat.
Christian T Sinclair, MD, FAAHPM is the co-founder and lead moderator of #hpm chat, editor of Pallimed, president of the AAHPM, and a palliative care doctor at the University of Kansas Medical Center.
When: Wed 07/13/2016 - 9p ET/ 6p PT
Host: Dr. Christian Sinclair, and Dr. Meredith MacMartin
Follow @hpmchat and go to www.hpmchat.org 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 tchat.io for ease of following. You can also check out the new site dedicated to #hpm chat - www.hpmchat.org
If you seem to always forget about the chat until it is over, you can always set a calendar reminder!
For more on past tweetchats, see our archive here.
*Occasionally people ask why #hpm and not #hpmc? #hpm was not a widely used hashtag, but #hpc was already getting lots of traffic for people to talk about Hewlett-Packard Computers (which has now morphed to High-Powered Computers). The first organizing hashtag for our field was #AAHPM for the 2009 Annual Assembly. As the Twitter tribe for our field was small back then, the decision was made by me to stick with #hpm since it was close to #AAHPM, and not staked out by any other group. We now recognize it as hospice and palliative medicine/care and have all professions well-represented at our chats.
Friday, July 8, 2016 by Christian Sinclair ·
Thursday, July 7, 2016
Well, I've been practicing palliative medicine for 10 years - 11 including my fellowship. So I feel like maybe I can take off my young turk hat, and put on my grumpy old man socks (I'm looking at you Bob Arnold and David Weissman) and start complaining.
What I wanted to complain about is the use of euphemistic, moralistic, and/or confusing terminology in our field, to describe our clinical work, and suggest we'd all be better off if we just said what we mean, as cleanly as possible. All of medicine has this problem, but palliative care you are my tribe, so this is what I'm going to complain about today and over the next four weeks.
During my training, I quickly got taught to avoid damaging, inaccurate, or inflammatory/scary phrases like "withdrawing care," "terminal sedation," "there's nothing more we can do," "pull the plug." So I stopped using them (although I'll note I have patients or families say the latter two to me all the time as they describe what they are deciding or what's happening). However we've got plenty of our own euphemisms in palliative care, although none as horrid as 'withdrawing care'.
This will be a 4 part-er and discuss 'comfort care,' 'compassionate extubation,' 'palliative sedation,' and 'assisted death.' I appreciate perhaps all this is a little cranky, and look forward to readers' responses, push-back, alternatives, etc. Sharpen your quill. In particular, if someone can counter-propose a non-euphemistic-but-as-nearly-parsimonious alternative, let us know. I'm not going to talk about 'serious illness,' because I don't know quite what I'd say, but I appreciate it has its problems. I don't think it's as egregiously messed as 'palliative sedation' or the others, however.
I need to acknowledge that all language is 'loaded', full of multiple meaning/connotations, historical context, etc - I get that - I'm arguing however as much as we have a choice to be clearer/more accurate/more transparent we should do so. I also appreciate that some of these terms are used as a sort of argot, an in-group short-hand ('we all know what we are talking about'), and that's fine I guess, but I still think we (in medicine, in healthcare, in life) should collectively try to err on saying-what-we-mean-clearly, as much as we can. Certainly, if we're using an argot, it should never be used in front of patients. Let the politicians have their double-talk, we're better than that.
So, grumpy socks on.
"Comfort care." "Comfort measures." Ok, I'm starting with an example that's just going to prove to you that I'm just being grumpy and vapid, because this is the one term of the 4 that I still use (in discussion with other healthcare professionals), because it is widely recognized amongst us healthcare professionals, and replacing it with the huge mouthful of 'a plan of care in a patient who is dying in which the goals of care are to prevent and alleviate suffering but not to prolong life/the dying process' is irksome, and runs the risk of the people who you're talking with deciding you're a pompous jackass.
So, yes, I say it, but only internally, I treat it as jargon, dirty, dirty jargon never to be spoken in the presence of patients/families.
My problems with it are two-fold.
One, it amplifies the already irksome and unnecessary dichotomy we have set up in medicine between 'cure' and 'comfort.' I'm no fool, I know sometimes there really is such a dichotomy, you can't have one without the other, but if remember from palliative care 101 eleven years ago, what we are trying to do in palliative care is to reduce the gap between the two, to help our patients feel better as they live longer. This is what the whole 'upstream' 'concurrent' palliative care idea is about, right? So I don't like reinforcing that chasm. Someone on one of my teams years ago starting saying 'comfort measures only' (for all I know this language has been widespread for years, I don't remember it however prior to the late 2000s), to underline the idea that *all* our patients should be receiving comfort measures; and for most of our patients who are imminently dying, the plan adjusts such that 'comfort measures' are all they are receiving, medically. "CMO" remains a commonly used, in-house argot
Two, it's confusing for patients and should never be said in front of them. I've seen it lead to stupid miscommunication many times. Like someone asking a patient 'Do you want comfort care?' 'Do you want us to focus on keeping you comfortable?' and the patient saying 'Yes of course' not realizing that the clinician was actually saying 'Should we stop efforts to prolong your life and *only* provide ongoing interventions to alleviate symptoms/provide comfort?' It's kind of like the infamous consult we've all had where it's like 'the patient wants hospice care please help arrange that' and you get there and find out the patient was asked something along the lines of 'Do you want to go home?' 'Do you want support at home to keep comfortable?' and of course the patient wants this, who the hell doesn't, but it was never actually explained to them that hospice implies discontinuing life-prolonging treatments, and not coming back to the hospital for 'aggressive measures.' (I know, I know, not always, there is some nuance here, but this is basically what enrolling in hospice implies.) Friends who work in hospice - these patients are enrolled all the time, right, and you go visit them and realize they have no clue what they just signed up for? They thought they were signing up for help being comfortable, and people coming to visit them at home, but not discontinuing active attempts to keep them alive.
Drew Rosielle, MD is a palliative care physician at University of Minnesota Health in Minnesota. He founded Pallimed in 2005. For more Pallimed posts by Drew click here.
Illustration Credit: Christian Sinclair CC-BY-SA-NC
Thursday, July 7, 2016 by Drew Rosielle MD ·
Friday, July 1, 2016
A couple of years ago I wrote a Pallimed article called, "We Don't Know Death: 7 Assumptions We Make about the Dying." Having knowledge of our assumptions is a first step, but what do we do with that knowledge? Since I wrote that article, I have further contemplated the "so what" factor of the assumptions to develop suggested interventions.
This article is the fifth in a series of articles where I take each assumption from the original article and explore the concept in greater depth to include implications and possible interventions. In my last article, I wrote about the assumption People don't want to be alone when they die.
Here is our next assumption: Family matters will get resolved.
A bestselling book by Dr. Ira Byock, The Four Things That Matter Most, suggests that at the end of the day, or at the end of life, it all boils down to these simple thoughts:
"Please forgive me,"
"I forgive you,"
"Thank you,"
and "I love you."
The book asserts that we can have powerful emotional healing within our relationships if we remember what matters. It is one of my favorite books on end of life.
As a hospice social worker, I have been witness to some powerful reconciliations at end of life: a daughter who forgave her mom for alcoholism, a son who forgave his dad for the divorce, siblings hugging it out.
We sometimes even see the patient's physical symptoms resolve. "Terminal restlessness" may go away when that long estranged loved one finally visits. We see the unconscious patient's brow relax. The effect of resolution in the patient is physically apparent and they die with a peaceful expression on their face.
Sadly, though, we have to acknowledge and remember that sometimes the reconciliation doesn't happen. The daughter will never go to the nursing home to visit her dying mother. The brothers will not put aside their differences despite a shared love for their dying father. The patient will not forgive the grandson who stole from her.
Unresolved conflict can be difficult for some hospice and palliative staff to accept. We know how much better they will feel if they can just let go of past hurts. We know that if they hold grudges, they might hold it for the rest of their lives. Is there something we can do or say to help them understand?
Maybe. Maybe not. We have to remember it is not our family and we don't have the complete picture. We should not go overboard trying to set up a reunion or reconciliation because of our own idealized view of relationships. It is easy for us to get caught up in the situation if we are repeatedly reminded by the patient or primary caregiver of the desire for contact with another family member. Remember, it takes two to reconcile.
A patient or other family member may even ask staff to make a phone call to the estranged family member on their behalf. They might hope that a staff member's notification will be taken more seriously. They might hope we have a way with persuasion where they did not.
This intervening is not advisable. In social work, we call this triangulation. Triangulation means we are getting in the middle of things and taking sides. We have to let go of the romanticized notion of our personal role in helping to resolve a 30-year old dispute at the deathbed.
Suggested Intervention: Assist family members with talking through how to reconnect to a loved one, however, avoid interjecting yourself in the middle of the situation. You can help them with phrases on how to reconnect.
We may not be the only ones who are hoping to see a reconciliation. There are times where a family member who is close to the patient is hoping the patient will resolve issues with another family member. Sometimes it is not a matter of an interpersonal dispute, but rather the primary caregiver is disappointed that others are not visiting patient. This is especially painful for the hopeful one because the patient is dying. This is that other family member's last chance to make things right. The high expectations one family member has of another can cause frustration for all parties involved.
Suggested Intervention: Provide emotional support to family members who are distressed by non-involvement of other family members. If appropriate, encourage them to express their feelings directly to these other family members.
There may be times where we are in contact with the estranged family member. For example, when the Power of Attorney (POA) of a patient in a facility does not visit the patient. They have their reasons for not wanting to be there. If we do our part to inform the POA that the patient is dying, and they still choose not to visit, we have to accept their decision.
Suggested Intervention: Allow family to stay un-involved if they choose. Provide supportive listening if they feel they want to explain why they are estranged.
Although we may not personally have experienced extreme family dynamics such as abuse that led to estrangement, we have to acknowledge there are situations that warrant a relative's choices. It is sometimes impossible to fully understand the contempt a family member has for the patient when what we see is a sweet, kind, and vulnerable person. We do not have all the pieces to the puzzle. We may not have any idea what was experienced in the relationship. Even if we disagree with the reason for the estrangement, we have to be mindful to be accepting of the feelings a family member has.
Suggested Intervention: Self-reflect on our own feelings about non-reconciliation.
The most memorable advice I was given as a new social worker was to remember the acronym: NATO - Not Attached To Outcome. The best support we can provide to patients and families is to provide loving kindness without attachment to how things "should" be in their lives and relationships.
Lizzy Miles, MA, MSW, LSW is a hospice social worker in Columbus, Ohio and author of a book of happy hospice stories: Somewhere In Between: The Hokey Pokey, Chocolate Cake and the Shared Death Experience. Lizzy is best known for bringing the Death Cafe concept to the United States. You can find her on Twitter @LizzyMiles_MSW
Friday, July 1, 2016 by Lizzy Miles ·
Thursday, June 30, 2016
July 1, 2006 was the day I became a staff palliative care physician at the Medical College of Wisconsin, after having completed my fellowship there. So it's been 10 years I've been doing this, and I've been reflecting a little on what's changed in those years. So here are my thoughts. I don't want to pretend all of these are profound, most of them have been said by others before, and better, but things have changed in these 10 years - I've changed - and I decided to write a little about it. Much of this is just my own perceptions of things, a lot of them are my own misconceptions probably, and I don't want to pretend to be speaking for the field, or anyone else but me. I should note that my clinical work is ambulatory palliative care, and inpatient consultation, not hospice work, which undoubtedly influences some of these perspectives.
- Clearly, the burning platform in contemporary healthcare that created the need for palliative care, still exists, and probably is even more burning than before. Patients with advanced illness are all too often lost, poorly informed as to what's going on/what's realistic, overwhelmed, suffering in all dimensions; families too. When we're involved, I think we help mitigate this somewhat, but the need remains huge, and is getting huger. Yes, huger is a word.
- Along those lines, I remember having this vague sense of professional vulnerability and territoriality 10 years ago. Worries we were going to do so well we were going to put ourselves out of business! All these other doctors would learn how to do family conferences and dose opioids-like-a-non-idiot and then we'd have nothing left to do. Good god that was so naive. I think part of it was also a growing pain worry that we weren't a real specialty, we were impostors, we don't have well-defined skills or domains that separate us from the rest of medicine. I can't remember when I stopped worrying about that. The need is so huge we'll never put ourselves out of business (the lack of a business model may, but not the lack of need), and I think I've become far more comfortable acknowledging we are specialists, we do have skills that are rare (to be collected all in one person/team) outside of palliative care programs, and we should be very proud of what we do. Most of this I think I learned from my fellows, especially the mid-career ones, who came into fellowship knowing they were good at this stuff, and they were for hospitalists and family docs and EM docs, only to realize holy christ they had a lot to learn to function as a highly effective palliative specialist in contemporary medicine. Their angst helped me see that. The people who have been yelling for years we need to train all the generalists to have better generalist palliative skills are 100% right, andI do look back on my early queasiness about this with astonishment.
- I spend a lot of time, probably wasted, asking myself stupid questions like if I could help my colleagues do one thing differently/better, what would improve the lives of our patients the most? It's usually something like being more paternalistic. It's such a toxic word I know (I think it's probably best to replace 'bad paternalism' with 'authoritarianism' which I think is a better description of what we were getting away from in medicine in the late 20th Century), but the longer I've done this the more I've become convinced that it would greatly improve the lives of our patients and reduce suffering if we were more paternalistic. Probably a better way of stating it would be if we gave patients much more guidance and direction as they approach the end of life. Sometimes when I'm teaching residents about code status discussions and early on talk about if they think a DNR order is indicated they need to, are obliged to, actually tell the patient that, I am amazed at the pushback sometimes "you can't say that." It's entirely fucked up, if you don't mind me saying so. Despite the so-called primacy of autonomy in contemporary medicine, us doctors and clinicians walk around all the time telling patients what we think they should do, what we think the right thing is (it's time to start medication for your blood pressure, you need a colonoscopy, your mother needs to be admitted to the hospital, we need to start dialysis soon). Most of us have figured out a way of doing that without being authoritarian, I'm not talking about not discussing the options, the pros/cons, but we still blithely and routinely and without thinking twice tell our patients 'you need a colonoscopy,' 'I think you should be admitted to the hospital,' etc. I'm convinced the world would be a better place if more people had the same approach to discussing end of life care, code status, etc with patients. It's this weird thing where we start treating end of life or code status (in dying patients) decisions as some sort of human right, where people have unlimited autonomy to decide whatever, instead of a collaborative, therapeutic decision in which our knowledge of the medical aspects of it (what's realistic etc) are key.
- You kinda get good at doing your work, and it's really easy to forget how tough it is for some of our colleagues in medicine and nursing. The patient is crying, the family are upset, they want things medicine cannot achieve for them, a young person is dying, a child is losing a parent, a family can't make a decision. You can be very, professionally aware of all that, in touch with it, thinking closely about how to help these suffering people, working closely with your great interdisciplinary team to figure out how best to help them, and it's just kinda doing your day to day job to do that, and forget that that sort of work is very foreign, very challenging, very outside of the 'safety zone' of some of your colleagues outside of palliative care. Not all of them, of course, but I still find myself surprised as I'm talking with a colleague and I realize 'OMG they are really being irrational about this situation' and realizing this space we are very professionally comfortable in is not a space they are comfortable in.
- Upstreaming, mainstreaming, making palliative care concurrent, really is happening. In fits and spurts, piecemeal, but I am seeing so many more patients way upstream today than I was 10 years ago; and I'm seeing so many more 'survivors.' People who nearly died but the allogeneic stem-cell transplant worked, or 10+ year survivors of widely metastatic breast cancer. In this context I have had to learn opioid weaning and tapering - honestly this was a skill that I don't remember learning in my fellowship because it was just so rare. Now I do it all the time.
- My relationship with opioids has changed, a lot. It would be too much to say I bloody hate the things - I don't, they are the best we've got for many patients much of the time, and I do spend more of my time coaching and supporting patients to actually take the opioids and work through the problems with them, but I've become more and more impatient over the years for something better. So many side effects, so many patients for whom they end up being maladaptive and harmful. Not so much patients nearing the end of life, or patients with painful conditions caused by ongoing clear tissue damage (eg cancer), but we see so many patients now who aren't quite in that category, and for whom the approach with opioids I learned early in my career (which continues to be very effective for my patients near the EOL, and for many of them with significant tissue damage pain syndromes [I refuse to say cancer pain because I think the carving out of cancer pain as something therapeutically or morally special is just bullshit]) is maladaptive, harmful. I've harmed people - it took me some years and some mentoring to figure this out, and to develop a different skill set to try to help these patients, and it's not easy but that's also been fun (learning new things).
- It's weird, but it was several years into my career before I realized how important it was to give my patients encouragement "you can do this", I don't remember if I just missed opportunities for it earlier, or if the preponderance of my patients were so terminal that it never came up and now that our patient population has shifted I do it all the time.
- Methadone really is a helpful drug. I did not really appreciate that 10 years ago.
- We need more and better research, clinical research. I'm not an investigator, I know it's easy to complain, but I've become really demoralized with the lack of good clinical research. Like, for instance, what the actual risk of QT prolongation is with methadone, etc - so many people are super queasy about it but the actual risk hasn't even been defined, and expert-panel consensus pronoucements don't count.
- Advance directives and advance care planning, especially in patients who aren't living with serious illness, should be considered a novel intervention that should be investigated, but not some sort of foregone conclusion as being helpful. The research showing that it is helpful is just not there, it is very limited, and actual trials of advance care planning have been few and have struggled to show actual improvement in patient-relevant outcomes. I want to be clear that I very very much believe that talking with patients with serious illness about their future, options, choices/decisions/scenarios they may be faced with, preparing them and their families for that - that I believe is a very good thing. A profoundly good thing which would transform medicine if we did it better. However, health systems spending millions of dollars on getting people to complete forms should be considered an unproven, investigational intervention. When I talk about this, and it's an uncomfortable thing to talk about in palliative circles, I'll often ask palliative care people - How often are you just like "Oh yeah, I am so grateful that patient had a health care directive! It really helped their situation!"? The answers range from 'rarely' to 'never.' I have appreciated Rebecca Sudore's and Tara Fried (and colleagues') discussion of this over the years, and research, on how we need to think about ACP completely differently (and, I'd continue to add, consider it a novel intervention which needs investigation, prior to widespread use/investment). I also think we probably need to reconsider the goal of advance care planning as we research it, and move away from the goal being somehow examining congruence between what people say they want on paper and then what happens (too much research has focused on this), and instead reconceptualizing it as an essentially palliative intervention to reduce suffering (emotional, but also perhaps physical) for patient and family. I do think that line of research has promise, but getting people to decide things in advance, not so much.
- I'm not sure palliative care is going to save American medicine, but I do think the model of how palliative and hospice teams do care (which is not a model we invented or own I need to acknowledge - geriatrics teams, long-term care teams, rehab teams, some primary care programs, & many others do this and were doing this before us) is one of the only ways to make contemporary medicine a humane place to work. I'm talking specifically about doctors and medical practitioners here I guess. I don't pretend to 'know the solution' for what ails medicine in 2016, but the current environment we have now in which docs are still mostly measured on volume, and how well we composed a nearly-worthless-trash-filled-but-highly-billable Epic note is a catastrophe. Pure shit. Creating interprofessional, high-functioning health care teams which are measured on patient-relevant outcomes and not volume and how complete your fucking notes are, in which the physician's role is to be a medical/medicine-leader, support other clinicians' medical work, and doing high-impact but lower-volume complex clinical patient care has got to be the way forward.
- Even more now than 10 years ago, I am just so goddamn grateful that I get to do what I do. Not some of the crummy paperwork/admin stuff, but being able to care for patients as part of a palliative care team, to practice medicine in this way...I feel so lucky. It's good work, and I'm glad I stumbled into it a decade ago, and I'm so grateful to the people who taught me during my fellowship (I still quote you to this day Lisa Marr, David Weissman, Linda Blust, Jo Weis, Sandy Muchka, Joan Golden, Ruth Drazewski, and many more), and those who have taught me in the subsequent years to. It's a good gig, stamping out suffering.
Thursday, June 30, 2016 by Drew Rosielle MD ·
Wednesday, June 29, 2016
In the summer of 2014, my sister-in-law, a new mother, died of cancer after 11 years with her disease. Although doctors gave her the best care they could, as a health researcher focused in cancer care, I wanted to do better for people like Clare. Then, at a scientific conference that fall, I learned that others had the same desire. Representatives from the National Cancer Institute were asking for studies to improve care for adolescents and young adults, including at the end of life. On the plane home, I started working with my research ideas. I realized that to know what young people with advanced-stage cancer need, want, and value, we need to ask them directly. That's what the Clare Project is doing.
I was fortunate to get support from the Group Health Research Institute Development Fund for pilot work. My team and I started by interviewing a few young adults with end-stage cancer. I learned so much from them about their concerns and values. Now, my Clare Project team of Drs. Marlaine Gray and Evette Ludman and Tara Beatty and I are taking a new approach for the next phases of our work.
A personal approach for a personal project
Clinical studies usually recruit people through the health system, with waiting-room posters or physician referrals. Because our work asks intimate questions about end-of-life priorities, we wanted something more personal. Clare used social networking to keep in touch with friends and family, so we started a Facebook page and a blog to tell our story. These have been wonderful for connecting with people who support our research. But we've found an even better way to engage with patients.
Based on many helpful suggestions, we started looking into online communities for young people with cancer. Through social media like Twitter, patients and caregivers are meeting virtually for empathy, encouragement, and practical advice. These communities make patients feel less alone. They are places to learn and share about real issues such as how to handle treatment side effects. The people in these groups aren't tech geniuses or first adopters. Many joined Twitter only when their health status spurred them to find others with the same illness. Connecting with people through these forums takes time and in the end, is highly efficient.
Marlaine, especially, has spent hours reading blogs, listening to podcasts, and following Facebook and Twitter feeds to learn the culture of online communities for young adults with cancer. This activity alone has been invaluable for our research by showing us the diversity of experiences, issues, and challenges that people are talking about. We're still learning about blogging, posting, and tweeting, and we're grateful to everyone who has allowed us into their conversations. By trying to be respectful members of these communities, we've been able to reach out directly, one-on-one, to potential study participants, to ask if we might talk with them. Everyone we've asked has said yes.
The future of patient-centered research
Our work is going in many new directions. We just received National Cancer Institute funding to understand nationwide trends in end-of-life care for adolescents and young adults. In the next phase of the Clare Project, we're going to ask caregivers and health care professionals what questions people have about care and treatment and how our research can answer them.Please contact me and see @clareproject if you want to know more. My family is proud that Clare, who was a high school biology teacher, has a legacy in research.
I'm committed to having patients, caregivers, and health care providers help me formulate, conduct, and spread the word about my research. I'm convinced about using social media to do this. As an epidemiologist, I've changed the way I think about a study population. It can still be people connected geographically or by a health care system. But it can also be virtual: people meeting online to discuss their disease, how it is treated, and what they think about their treatment.
I've experienced how patients are willing to directly and honestly communicate their ideas to researchers using social media and how they are rewarded by participating. I think we should all realize that in the 21st century, this is the best way to connect with people affected by our work. Patients, caregivers, and providers are online, talking about the issues we're studying. Shouldn't we be listening?
Join us Wednesday, 9 eastern/6 central for #hpm chat to discuss palliative needs withing the Metastatic and Advanced Young Adult Cancer Community (#mayacc), We'll discuss effects on patients and caregivers, and how The Clare Project hopes to bring better understanding to the needs of those patients and caregivers.
Karen J. Wernli, PhD, is a Group Health Research Institute assistant investigator working with The Clare Project.
Originally posted at the Research Health Group Blog
Wednesday, June 29, 2016 by Christian Sinclair ·


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Hi there,
I am just beginning to figure out how to HS my ds for kindergarten. I find so many great resources here and on other sites but I get a little overwhelmed with all the info. I am seeking tips or great websites to get started that have really helped you out. I live in BC, so any info pertaining to my province would be greatly appreciated. I have always heard that the gov gives money to help subsidise home learning but can't find info in our province. Any help would be warmly welcomed
I can't say about BC, but I'm in Alberta and here it is required that you register with a school board. There are quite a few school boards that I was able to choose from and we found a good fit. We are 100% parent directed (non-blended, traditional homeschooling) and as long as we register with a school board by the end of September of the beginning of the school year we have funds available to us for reimbursement. For us it is around $700. If you go with a 100% teacher-directed program the funds increase to around $1400, but you have to pay a program fee and you have someone telling you what to do. You can go with a blended program and the funds will be somewhere between the 2 numbers.
Since Kindergarten is not mandatory in Alberta (not sure about BC), there is no "kindergarten homeschool". No school board here would take my son until he was supposed to be in Grade 1. So no funding for kindergarten which was okay because we didn't need any. I will try to look around and see if I can find any helpful links for you.
I could be wrong, but I believe Alberta is the only province that gives money to homeschoolers.
hey, the school we are signed up with in bc (hands on home learning) doesn't 'give' us money but will pay directly for approved activities and supplies up to......i also know that the self deisgn program does it a bit different and gives the parents a preloaded card to pay for approved activities and supplies.
in case i wasnt clear, this is information for British Columbia
Yes, in BC you have the option of enrolling your child with a "distributed learning" program and receiving access to funding. Funding varies by program but seems to average about $1000 per full-time child. By law the money can't be dispensed to the parents, not even in the form of reimbursements for receipted educational purchases. So programs have developed various ways of paying vendors or service providers directly on the child's behalf.
Along with access to that funding comes obligations, as you can probably imagine. No free lunch. Again, it varies by program, but you might be required to keep records, submit portfolios and/or adhere to an approved curriculum approach. Some programs are light on the curricular control but heavier on the reporting end. Others minimize the reporting, but expect adherence to particular structured courses of study. There's a lot of variety out there, and usually something for everyone.
The final alternative is to declare yourselves as Section 12 homeschoolers (refers to Sections 12/13 of the Education Act). No funding. No reporting. Total freedom.
Mountain mama to two great kids and two great grown-ups
I'm in BC and trying to figure out HSing for K next year as well. One program in the Fraser Valley that has different ways of doing it helped me understand my options. It's a Christian online school, but even if you are not Christian I found the table helpful in understanding the different situations - homeschooling, distance learning...
Self Design is an unschooling based "school" that you can enroll through that appears to me to give the most flexibility, but I'm still trying to figure it all out. It seems like a person can get up to $1000, including $300-400 to pay for internet access, to pay for cirriculum, activities, etc. Most of the places I have looked into you tell the school what to buy for you and they do it (within reason). Self Design seems to put the money in portions on a prepaid visa, and what you buy has to fit in with the learning plan you design with them (but that plan can be amended whenever it needs to be).
If you are willing to have some oversight (a teacher or learning consultant and some standardized tests), the government will help pay for cirriculum and activities. If you want total independence, then you get it - BUT, you then have financial independence too.
ETA: A thread I started quite a while ago might be informative for you - I have been all over the map in ideas of how to educate, but a lot of people who have done Self Design chimed in (along with others who know about schooling in BC).
Oh, I should have said that if you register as a homeschooler you get a little money, $100ish?, but if you don't even want to register you don't have to. I am not sure if people who are registered as homeschoolers then are supposed to take the standardized tests...
That's true of a few homeschooling-friendly independent schools. If you register with your local public school district, you probably won't get any funding. You may get access to any surplus learning resources they have available though. And no, there's no requirement to take standardized tests if you're a registered homeschooler.
Mountain mama to two great kids and two great grown-ups
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With this audio analyzer (depending on the model), two, four or eight channels are processed in parallel; and by cascading multiple instruments, users can simultaneously trigger up to 48 measurement channels, which cuts down on measurement time. Designed for system applications, it features low height, and comes without front-panel control elements or integrated display. The instrument can be remote controlled via LAN, USB or IEC/IEEE bus. In combination with an external monitor, mouse and keyboard, it becomes a manually operable measuring instrument for a lab bench. It has an integrated control PC, and the required software is already installed.
Aug. 4, Columbia, Mo.
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Radio Advertising Bureau's Dallas Office Relocating to Irving
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Freeform Greenlights Mermaid Drama 'The Deep'
Ken Lawson Promoted to Senior VP, General Sales Manager at Twentieth Television


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Getting the most out of the Layers panel
Getting the most out of the Layers panel
So we now have a clear understanding of just how valuable the Layers panel is. We know that we can use it even if we aren't creating layers at all inside of Illustrator. Keeping all that in mind, I just wanted to show you a few quick tips and tricks about how to get the most out of the Layers panel itself. Now I'm going to open up the flyout menu, or the Panel menu here, of the Layers panel itself. I want to show you a few settings here. First of all, let's scroll all the way to the bottom where it says Panel Options. If I choose that, the Layers Panel Options dialog box opens up, and there are several settings here.
First, let's focus on Thumbnails itself. Thumbnails are the little icons that appear to the far-left of the layers themselves that give me a little preview of the artwork on that layer. Between you and me, I have no value at all in these little teeny little thumbnails here. I really can't see at all where this artwork is, and here's a little secret: Illu...
Getting the most out of the Layers panel provides you with in-depth training on Design. Taught by Mordy Golding as part of the Illustrator Insider Training: Rethinking the Essentials
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In August, the Maritime Labor Convention (MLC) of 2006 came into force, bringing a consolidated legal framework governing the rights of seafarers. What that means depends on what flag state that a mariner sails under. And, even if a particular nation hasn't ratified the code – such as the United States, for example – the implications might still be the same. Indeed, the first ship detention has already been reported. The Convention introduces many things that yesterday's seafarers could only dream about. Nevertheless, MLC will be a two-way street; for mariners and shipowners alike.
The new rules are sufficiently ambiguous that compliance, in many instances, is left open to the interpretation of those writing the local version of the rules. In general, life aboard the world's 45,000+ deep draft ships ought to be getting better. Hence, a lingering shortage of qualified mariners will potentially afford seafarers the rare opportunity of being choosier about which ship they sail on. For shipowners, one thing is crystal clear: compliance with yet another global regulation is sure to impact the bottom line.
Our feature story in this edition centers on one of the more interesting and certainly the most diverse and aggressive business plans in the maritime industry today. Shane Guidry has Harvey Gulf International Marine on a course that promises to upend the conventional offshore support model forever. Introducing groundbreaking dual fuel tonnage loaded with state-of-the-art crew amenities (there won't be any MLC violations here) and any number of innovative initiatives, Harvey Gulf is arguably setting the stage for the long awaited "flight to quality" and the "two-tier" Gulf of Mexico OSV charter market. How it all plays out could ultimately redefine who does business in this market, where they compete, and the manner in which the job gets done.
As operators (perhaps) prepare to ramp up creature comforts and extend better on board communications to their mariner employees as both a means to compliance and to attract and retain the best talent, seafarers themselves also have new responsibilities. That's because no longer will mere compliance with baseline STCW requirements be enough for the privilege of going to sea. Increasingly, the concept of "performance-based assessments" is becoming the rule, rather than the exception. For many operators today, the practice of blindly hiring a mariner on the basis of documentation alone has come to an end. Markedly improved simulation training is at the root of all of that, and therefore has a prominent place in this edition.
Finally, and as piracy spreads from region to region like proverbial wildfire, the security of ships and supply chain also falls under the general heading of crew welfare. In this edition, we take on maritime security – at sea and ashore. In both cases, technology is the key to success in both venues. Finance, technology, innovation and corporate vision all come together in this edition of Maritime Professional, charting the way forward for a rapidly evolving industry. As you navigate your way within the pages that follow, see if you do not agree.
(As published in the 3Q edition of Maritime Professional - www.maritimeprofessional.com)
Maritime Today
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Norwegian oil firm Det norske said it expected to reach full production at its Alvheim FPSO (floating storage, offloading and producing unit) overnight after a leak,
An International Maritime Organization (IMO)-led workshop in Maputo, Mozambique is supporting countries in south-eastern Africa in implementing the STCW (Standards of Training,
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Weather Channel Forecasters are predicting a "near-average" hurricane season for 2016, but warn that an average season does not mean businesses and residents shouldn't prepare for the worst.
Further progress towards identifying and designating Particularly Sensitive Sea Areas (PSSAs) in south-east Asia has been made during a regional meeting in Lombok, Indonesia (27-28 July).
Libyan oil exports from closed ports should resume in no more than one to two weeks after a deal was signed between the government and an armed brigade controlling the terminals,
Standing NATO Mine Countermeasures Group 2 (SNMCMG2) has completed its third deployment into the Black Sea under the command of Captain Ramazan Kesgin, Turkish Navy.


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Comments about 'Paxton Norton, Utah 3-year-old with rare genetic condition, was a 'magnet of joy''
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Brother Benjamin Franklin
Orem, UT
Poor little guy. What a tragedy! We will keep this little one in our thoughts.
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Eagle Mountain, UT
Brother Benjamin, I disagree!! What a beautiful little miracle his sweet life was! No tragedy here, just sacred beauty! Thank you, Norton Family, for letting us share in the sweetness.
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"There aren't a ton of bands today that are as real with their music or as raw."
"Windowpane is not only one of the best musically gifted rock outfits in town, but also one of the most entertaining."
"2016 has been a big year for Windowpane. They released their self-titled album (I am obsessed with it), threw a monster album release party to mark the occasion, had their new single "Words & Nothing More" picked up by KISW for the rock community to gobble up, released a documentary called "There Is No Such Thing As The Record Label Fairy" AND will be playing KISW's Pain In The Grass on the main stage on August 21st. Can they fit anything else into their schedules!? You betcha..."
"Headliner Windowpane vocalist/guitarist Glenn Cannon welcomes fans to the show with humility and sincere appreciation but doesn't hold back during their performance, singing with emotion and authority. This is true of the entire band's stage presence. At times they even look angry, wielding their guitars like weapons."
"When Windowpane decided to throw their self-titled CD release party, they knew just how to do it!"
"Windowpane, named after one of my favorite pharmaceuticals, made their way to the great northleft and became one of the hardest working bands in the Seattle scene, selling over 10,000 units to date without major label support."
"Windowpane plays music in a way that stands to redefine the standards of today's live acts and invalidate today's overworked music. It's 100% hard rock: delivers all the elements us discriminating rockers treasure as our culture of music: but WINDOWPANE does it with what cant be seen, heard and carries just as much power as the instruments in their skilled hands: There is an understated, pride in ownership, mother fucking take it to the bank QUALITY that makes them unique and special. In today's musical environment, therein lies the highest premium I place on music..."


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Older guy with grey mustache sucking and swallowing
- Runtime:
- 5:09
- Views:
- 87205
- Date:
- 3 years ago
- Rating:
- (147 votes) 99%
Older guy with grey mustache sucking and swallowing
love that hairy chest on the sucker!! mmmm
So erotic
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Damn, you make my balls ache the way you make love to that cock. The fact you are handsome and so very hairy chested just adds more ***** to my crotch. Love your work!


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enabled and will therefore experience limited functionality.
1 mile
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68,000 miles Manual, Hatchback, Silver, 2005, 54 plate, Petrol
History checked
26,000 miles Automatic, Hatchback, Black/Silver, 2009, 58 plate, Petrol
35,000 miles Automatic, Convertible, Black, 2008, 58 plate, Petrol
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13,279 miles Automatic, Hatchback, White, 2013, 13 plate, Petrol
22,022 miles Automatic, Convertible, Silver, 2011, 11 plate, Petrol
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30,500 miles Semi Automatic, Hatchback, Silver, 2009, 59 plate, Petrol
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70,000 miles Automatic, Convertible, Silver, 2008, 08 plate, Petrol
45,000 miles Automatic, Hatchback, Black, 2009, 09 plate, Petrol
10,190 miles Automatic, Convertible, Black, 2013, 13 plate, Petrol
68,000 miles Automatic, Convertible, White, 2010, 59 plate, Petrol
37,500 miles Automatic, Hatchback, Silver, 2009, 59 plate, Petrol
11,850 miles Automatic, Hatchback, Silver, 2005, 55 plate, Petrol
29,700 miles Automatic, Hatchback, Silver, 2012, 62 plate, Petrol
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text:
Assume that the circuit in Assessment Problem 4.21 is delivering maximum power to the load resistor R.
a) How much power is the 100 V source delivering to the network?
b) Repeat (a) for the dependent voltage source.
c) What percentage of the total power generated by these two sources is delivered to the load resistor R?
Reference: Problem 4.21
a) Find the value of R that enables the circuit shown to deliver maximum power to the terminals a,b.
b) Find the maximum power delivered to R.


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Hotels near Alcaldia (City Hall)
Search hotels near Alcaldia (City Hall) in San Juan
Trending now in San Juan
- Most bookedHotel El Convento
116 people looked at this hotel in the last hour
Most recent review
"This hotel has all the charm and elegance of an old world hotel, but it has all the modern amenities needed for total comfort. The added touches, such as tea and coffee 24/7, and a complimentary wine and cheese hour make it a must. Plus, the location is perfect!"
M, Jun 2016, US
101 people looked at this hotel in the last hour
Most recent review
"The location of the hotel is at the heart of Old San Juan. Everything was walking distance including the restaurants, pier and other historic landmarks. There's a trolley stop right in front of the hotel where you can hop on hop off for free. The trolley has three routes that goes around Old San ..."
M, Jun 2016, US
100 people looked at this hotel in the last hour
Most recent review
"A great hotel and great location with very friendly night and day staff"
A Traveller, Jun 2016, US
83 people looked at this hotel in the last hour
Most recent review
"Had a great time here, the room was beautiful and the old building had a great old world charm. The bed was comfortable but be aware, this is an old building and you hear everything. But, the room came fitted with nice tv with Apple TV and a good air-con unit. Staff was probably one of the bes..."
A Traveller, Jun 2016, US
68 people looked at this hotel in the last hour
Most recent review
"The hotel is NOT fancy but it is clean and comfortable ... The staff was friendly ... If you are looking for a affordable place to stay in a premium location this is the place to stay"
A Traveller, Jan 2016, US
45 people looked at this hotel in the last hour
Most recent review
"Wow - what an incredible hotel. it is in a great neighbors where all the action is, yet it quiet at night. It is very simple but clean and the beach and Forts are here."
A Traveller, Feb 2016, US
28 people looked at this hotel in the last hour
Most recent review
"Owner was very helpful, carried our luggage up. Quick check in. Hotel door stays locked at all time, felt very safe, as there is no one on the front desk."
A Traveller, Jan 2016, US
28 people looked at this hotel in the last hour
Most recent review
"Outstanding hotel with great location in Old San Juan. Excellent and ample decorated rooms. Outstanding and friendly staff. Breakfast also included!!! Outstanding!!!!! THANKS!!!!"
A Traveller, May 2016, US
18 people looked at this hotel in the last hour
Most recent review
"Location can't be better, all the highlights for old san juan are walking distance and if you dont feel like walking just take the free trolley to go around just one block away. the hotel is new they still working in some small detail like the main entranc. Furniture,premium bedding, room was hug..."
A Traveller, Apr 2016, US
15 people looked at this hotel in the last hour
Most recent review
"very nice place excellent location the apt makes it a different experience however if you really must have wifi its not for you"
A Traveller, Jan 2016, US
Map of hotels near Alcaldia (City Hall)
- Condado Beach
- Puerto Rico Convention Center
- Jose Miguel Agrelot Coliseum
- Centro de Bellas Artes Luis A. Ferre
- Escambron Beach
- Plaza las Americas
- Dorado Del Mar
- Puerto Rico National Cemetery
- Castillo San Felipe del Morro
- Puerta de San Juan (San Juan Gate)
- La Fortaleza - Palacio de Santa Catalina
- San Juan Cathedral (Catedral de San Juan)
- Hiram Bithorn Stadium
- Convento de Los Dominicos
- University of Puerto Rico
- Casa Bacardi
- Castillo de San Cristobal
- Statue of Ponce de Leon
- Plaza Rio Hondo
- Barbosa Park
Hotels in San Juan near Alcaldia (City Hall)
Are you looking for a cheap Alcaldia (City Hall) hotel, a 5 star Alcaldia (City Hall) hotel or a family friendly Alcaldia (City Hall) hotel? You just landed in the best site to find the best deals and offers on the most amazing accommodations for your stay.
When you search for hotels near Alcaldia (City Hall) with Hotels.com, you need to first check our online map and see the distance you will be from Alcaldia (City Hall), Puerto Rico.
Our maps are based on hotel search and display areas and neighborhoods of each hotel so you can see how close you are from Alcaldia (City Hall) and refine your search within San Juan or Puerto Rico based on closest public transportation, restaurants and entertainment so you can easily get around the city. All the hotels details page show an option for free or paid onsite parking.
If you wish to see the hotels with the highest featuring discounts and deals near Alcaldia (City Hall), simply filter by price/ average nightly rate. We recommend you filter by star rating and read our genuine guest reviews so you can get the best quality hotel with the best discount.
One of the new features on Hotels.com guest reviews is that also show reviews from Expedia for Alcaldia (City Hall) hotels and the TripAdvisor Alcaldia (City Hall) hotels reviews so you can make sure that you checking with a reliable source. See the review scores on our San Juan hotel information pages.
Make the most out of your family vacation when you book your accommodation with Hotels.com – book your hotel near Alcaldia (City Hall), San Juan after reviewing the facilities and amenities listed for each hotel.
After booking your hotel near Alcaldia (City Hall), expect to receive your reservation confirmation in the mail in less than 10 minutes. The confirmation email contains more information on all nearby attractions, local directions and weather forecast, so you can better plan the days during your trip.
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The best hotel deals are here: We have Alcaldia (City Hall) hotel deals, Alcaldia (City Hall) last minute deals and offers to get you the cheapest Alcaldia (City Hall) hotel with our lowest price guarantee.


text:
The Top Ten Stocks for Wednesday, July 9
July 9 (Bloomberg) -- Bloomberg's Betty Liu, Julie Hyman and Matt Miller report on today's ten most important stocks on "In The Loop." (Source: Bloomberg)
Most Recent Videos
Apple and the Fed: The Week Ahead for ETFs
43:49 - Bloomberg Intelligence's Eric Balchunas examines the week ahead for ETFs with a look at what this week's Federal Reserve meeting and Apple's earnings report mean to the market. He speaks on "Bloomberg Markets." (Source: Bloomberg)


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List all words ending with aelrsy
No words ending with aelrsy found in this word list.
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Fleet Feet Sports & adidas present:Boston365 NOW
After qualification and acceptance into the B.A.A. Boston Marathon, you can join us for a challenging training experience leading you into the Marathon. You will be joined by USATF and Fleet Feet Sports Certified Coaches, as well as fellow Boston Marathon Qualifiers, for a 14 week training experience. Each week you will have a speed/interval workout on Wednesday evenings, and a long run on Saturday mornings. You will also be treated to a VIP experience during the race weekend courtesy of the Boston Athletic Association, The Competitor Group, Fleet Feet Sports, and adidas.
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It seems increasingly that Alberto Gonzales's attitude towards testimony before Congress entails spreading official truths that happen to be lies. He seems indifferent to the fact that he's sworn in before he testifies, and that federal law makes it a crime to make false statements to Congress. After all, he's the country's chief law enforcement officer, and that position carries with it complete immunity, right?
Here's another Gonzales perjury incident recounted in this morning's Washington Post:
As he sought to renew the USA Patriot Act two years ago, Attorney General Alberto R. Gonzales assured lawmakers that the FBI had not abused its potent new terrorism-fighting powers. "There has not been one verified case of civil liberties abuse," Gonzales told senators on April 27, 2005.
Six days earlier, the FBI sent Gonzales a copy of a report that said its agents had obtained personal information that they were not entitled to have. It was one of at least half a dozen reports of legal or procedural violations that Gonzales received in the three months before he made his statement to the Senate intelligence committee, according to internal FBI documents released under the Freedom of Information Act.
The acts recounted in the FBI reports included unauthorized surveillance, an illegal property search and a case in which an Internet firm improperly turned over a compact disc with data that the FBI was not entitled to collect, the documents show. Gonzales was copied on each report that said administrative rules or laws protecting civil liberties and privacy had been violated. The reports also alerted Gonzales in 2005 to problems with the FBI's use of an anti-terrorism tool known as a national security letter (NSL), well before the Justice Department's inspector general brought widespread abuse of the letters in 2004 and 2005 to light in a stinging report this past March.
The Gonzales remarks were not, of course, incidental banter. He appeared in response to requests that he address precisely this situation. And he consciously and coldly lied about it. Indeed, his track record of serving up whoppers to Congress is now unequalled by any modern cabinet officer. But in the Gonzales view, until the opposition can muster the 67 votes in the Senate to remove him from office, they can shove it. He serves at the kingpin's pleasure.
More from Scott Horton:
Conversation — March 30, 2016, 3:44 pm
Joseph Hickman discusses his new book, The Burn Pits, which tells the story of thousands of U.S. soldiers who, after returning from Iraq and Afghanistan, have developed rare cancers and respiratory diseases.
Context, No Comment — August 28, 2015, 12:16 pm
In five easy lessons
From the April 2015 issue
In Havana, the past year has been marked by a parade of bold-faced names from the north — John Kerry reopening the United States Embassy; Andrew Cuomo bringing a delegation of American business leaders; celebrities ranging from Joe Torre, traveling on behalf of Major League Baseball to oversee an exhibition game between the Tampa Bay Rays and the Cuban national team, to Jimmy Buffett, said to be considering opening one of his Margaritaville restaurants there. All this culminated with a three-day trip in March by Barack Obama, the first American president to visit Cuba since Calvin Coolidge in 1928. But to those who know the city well, perhaps nothing said as much about the transformation of political relations between the United States and Cuba that began in December 2014 as a concert in the Tribuna Antiimperialista.
Amount traders on the Philadelphia Stock Exchange can be fined for fighting, per punch:
U.S. Securities and Exchange Commission
Philadelphian teenagers who want to lose weight also tend to drink too much soda, whereas Bostonian teenagers who drink too much soda are likelier to carry guns.
Nuremberg's Neues Museum filed a criminal complaint against a 91-year-old woman who completed a crossword puzzle that was in fact a $116,000 piece of avant-garde Danish art.
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"Matt was happy enough to sustain himself on the detritus of a world he saw as careening toward self-destruction, and equally happy to scam a government he despised. 'I'm glad everyone's so wasteful,' he told me. 'It supports my lifestyle.'"


text:
Whether you are looking for Photography or photographic services, Hotfrog is the place to go to. Browse the businesses below in Puchong, Selangor or extend your search to nearby suburbs by using the left navigation menu. Hotfrog makes your search easier.
Puchong, Selangor
cThree is a community of photography enthusiasts that comes together every now and then to attend photoshooting events, share equipments together, me…
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SOUND MASTERS EVENTS is a one-stop event management company dedicated to providing our clients the best events with competitive prices. We at Sound…
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Good day, we are food photographers from foodphotography.com.my. We are really passionate on what we are doing and keen to serve you well .Do have look at our website.
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What inspires us as a professional wedding photographer? The moments & happiness we see through our lens....and we capture that moment for your safekeeping forever. We may not be the cheapest but we are affordable an…
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Event management services? Event consultant? Event support services? Welcome to Memoires Events! Your Event Management Solutions! Memoires Events is an established event management company that provide event management …
video shooting for wedding, dinner, engagement, birthday, anniversary, drama shooting, photography for wedding, dinner, engagement, birthday, anniversary, office events, exhibitions, news papers, make up , bridal
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High Quality Photostudio offering; portrait, product, profile and business video and photography. We are known to be very affordable with a low price.
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Pixie is a KL-based company that sells/rents custom made wedding gowns. Pixie also do wonderful makeup work, specialising mainly in bridal and commercial make-up. We believe in enhancing natural beauty via the use of c…
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We provided Bridal studio Packages/Indoor and Outdoor Photography , Commercial and
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Welcome to Maven Ads. Maven Ads is an integrated promotional design agency, we offer a wide chain of services, starting with graphic design, website development, commercial photography, video editing, corporate branding,…
PhotographerCommercial Photographyphotographic servicesVideo Editing
ZEN digital imaging & photography established in 1994.Since graduate from Brooks Institute of Photography in Santa Barbara Zain has start his own agency handling commercial photography specialist in Aerial photograph…
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Our sales representatives are reachable by phone and email At Camera2U, we have the right formula for what you are searching: High quality equipments, Low prices, Fast shipping and Warranty support That is…
We offer extensive tuition services to primary & secondary school students Daycare Services: We offer daycare services for children between the ages of 3 years to 15 years old
We have in store of up to 350 pieces of bridal gowns and is set to have additional pieces from time to time
Wedding PhotographyRetail
We are the expert with many specialist in tv, film & video production as well as anything photography. We have all the specialist working in their specialization not a few man shoot everything
We have expanded our business to sell all leading brands of products such as DSLR, Digital cameras, System Cameras, Action Cameras, Video Camcorders, Digital Lifestyle products, "FotoBuk" and wide range of related a…
TripodPhoto ProcessingDigital CameraOlympus
We are passionate teams of sharp shooter who's shooting for more than hundreds of weddings since 2006 but we do not use GUN
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puchong, Selangor
We bring you a popular range of digital camera rechargeable batteries that costs a fraction of what you'll normally have to pay
digital photographyDigital VideoDigital CameraPhotographic Equipment
MYFOTO STUDIO brings a fresh dimension to professional Indian wedding photography, co-founded by Indian wedding photographer Deepak K. Menon Vimala Perumal who specializes in photography of Indian weddings. We practi…
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Memoires Events has been privileged to be part of our client's many memorable events. We offer a comprehensive range of services from need analysis, planning, customised and follow- ups to execution on event day. We spec…
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Sophisticated, classy and well-planned website design. Ability to create high visibility on search engines for your website.
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