Author: Lisa Yauch Cadden

Empathy and the End of Life

Empathy and the End of Life

Sometimes in our line of work, our patients do not get better.  Sometimes, despite our best efforts, they get worse.  And sometimes they die.  This month  has been a difficult one, as the majority of my hospital caseload has included patients at the end of life.  I have also had a graduate student working with me. Needless to say, we have experienced many “teachable moments” together this month and my twitter feed has been surprisingly supportive (see posts/retweets @CCCSLPNET).

What  I have learned/tried to teach is:

The  importance of  understanding the patient’s goals and perspective.

The importance of withholding  my personal feelings/judgements while providing the most accurate information I can to explain the patient’s deficits.

The importance of alternatives, knowing that if ‘Plan A’ does not meet the patient’s goals, there needs to be a ‘Plan B’, and possibly a ‘Plan C’.

The importance of teamwork

I am fortunate to work with a wonderful team of physicians, nurses, dietitians, case managers and a great Palliative Nurse Practitioner.  Through these collaborations I have learned that the Palliative Care conversation, that “first conversation” can happen early, before the end of life, to help clarify the patient’s goals for care in  order to mitigate unnecessary care and  avoid unwanted returns  to the hospital. I have learned to avoid blaming the patient for their informed choices by endeavoring to eliminate the  term “non-compliant” from my documentation.  If after education, the patient decides not to follow my recommendations, that is their choice.  They are not non-compliant.  They are choosing a different course of care based on their goals/values.  I need to respect that.

My biggest contribution to my team has been in providing education regarding what alternative nutrition (G tubes) can and cannot do for chronically ill patients at the end of life. Knowing that G tubes are contraindicated in patients over 75, with advanced dementia, advanced/chronic illness, low BMI, previous aspiration and UTI and that there is no evidence that tube feeding in patients with advanced dementia prolongs survival, prevents aspiration pneumonia, reduces the risk of pressures sores or infections, improves function or provides comfort has helped our team in its quest for compassionate care.

It is always an on-going process.  Each patient is different and it is never easy, but we strive. I remind myself that it is an honor and a privilege to  assist in the care of these patients at this stage of their life…. That helps.

For more information regarding Palliative Care and PEG tubes see:
Plonk Jr., WM. To PEG or Not to PEG. Practical Gastroenterology. July, 2005.  pp 18-31.  Great summary with multiple additional references.

About the Author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.
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What are you thankful for?

What are you thankful for?

Please join me on the Soapbox on this Thanksgiving Day to share what you are grateful for.

I am thankful for so many things:

My family  because they possess unconditional love

My son because he is my greatest joy

My friends because they are such greats listeners

My patients who get better because they make me proud

My patients who don’t get better because they teach me humility

People who are pleasant because they make me smile

People who are not pleasant because they teach me patience

The good things which make me happy

The bad things which make me stronger

Chocolate when I am happy

Chocolate when I’m sad

Fleece sheets and a toasty fire on a cold winter night

A cool a breeze and an icy beverage on a warm night

Household appliances which work most of the time

A short commute

And…..

All of the support we have gotten for this website

Thank you so much

Happy Thanksgiving to All!

*****post what you are thankful for below*****…

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Look at what was in the bottom of the suitcase!

Look at what was in the bottom of the suitcase!

We’re midflight heading for ASHA 2012 ATLANTA and reminiscing about ASHAs of Novembers past.  Digging into our suitcase, we’ve found sage words of advice from trusted colleagues and a few laugh out loud suggestions to brighten any gray treatment afternoon.

George implores us to be Creative!  be Functional! Explore ALL the possibilities.

Build trust first – wise words from Julie.

Ginia has a delicious suggestion for bringing food to your session. And, few confections are better than ice cream.

Peter Boyle said, life is about finding the funny.  Don’t forget that at the therapy room door – smile, be humorous, stay positive.

Three words: practice, practice, practice.

Trust your gut.

Bracketology comes to us from Andy.  Andy, email us. We are interested learning more about this sports themed technique.

Pamela noted to get to know the neighborhood, for our home health based therapists. We would like to add, please do this during daylight hours and try not to look too suspicious.

Then there are the unusual suspects:

  •  Shaker Exercises.
  •  Oral Motor Exercises.
  • Kim suggested Exercise Physiology.  If you are reading this Kim, please contact us.  We need to know MORE!
  • Entire World of R.      Poor X; overlooked again.

And, when all else fails, Jenny recommends, laying on the floor and let them come to you.…

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When Rehab Came to Long-Term Care

When Rehab Came to Long-Term Care

For this entry of REFLECTIONS, the founders of this website decided to take a moment to reflect on our own careers in the field of Speech Language Pathology, particularly that portion that brought us together.

Way back in the very late 1980s/very early 1990s, we were both moonlighting as contractors in long-term care.  We had both come from in-patient rehab settings working with brain-injured adults and were looking to expand our skills.  Back then, SLP’s were required only on an ‘as needed’ basis in nursing homes. PT’s were required 6 hours a month and OTs were regulated to 4 hours.  There were no rehab teams, because rehab didn’t happen in nursing homes.  Nursing homes were for custodial nursing care.  If a patient had a problem, the home would call us. We would swoop in, do an evaluation and leave a long (sometimes very long) list of recommendations for the nurses to carry out.  We didn’t treat the problem.  Follow up was PRN – at the request of the nurse – if the problem didn’t resolve, given our extensive recommendations.  Thinking back, it is shocking how much we didn’t do.  Even more surprising was the fact that the head injury facility where one of us worked full time (in a department that included two other full time SLPs and two full-time SLP-As) actually occupied three wings of a four wing long-term care facility, and in five years of providing full time care, our department was called to the nursing home wing only once.

Then things changed.  In order to cut costs and defer care away from high priced hospitals, insurance companies and the federal government’s medical insurance plan, Medicare, began to reimburse nursing homes for rehabilitative care.  It was pretty much a pass through arrangement which allowed nursing homes to charge a fee for rehabilitation services which Medicare then paid.  This opened up huge opportunities for nursing homes and contract rehabilitation companies that provided rehab staff
(PTs, OTs and SLPs) to nursing homes.  This was now the mid 1990s and we found ourselves setting up departments and policies and feeding programs and language therapy in facilities that had never had them.

A population we always thought we’d just dabble in, in a setting no one ever liked, we began to love.  And then we started to teach other people (students and CFYs) to love it.  Senior citizens are awesome.  They are wise and hilarious and generous and aggravating. They allowed us into their home (the nursing facility) so that we could care for them.  It was a joy to see them improve, heartbreaking when they didn’t and an honor to shepherd them through difficult times as they approached the end of life.  The process transformed traditional nursing homes where people went to die into skilled care facilities where people lived, got better, sometimes went home or stayed and lived their lives in a place they could call home.

Then came more change.  Enter the Balanced Budget Act of 1997.  The Balanced Budget Act of 1997 was an omnibus legislative package enacted to balance the federal budget by 2002.  The Act resulted in $160 billion in spending reductions between 1998 and 2002 with Medicare cuts responsible for $112 billion of that total.  This became the real test of our love of long-term care.  We now of course, had to do more with less, but this is also when our programs started to grow and coordinate with nursing and our fellow rehab professionals.  We were a smaller more mobile band of therapists working hard to treat a population that viewed the nursing home as a short-term stop on their road to recovery. Before our entry into rehab in long-term care, no one would have ever thought that a patient would return to the community once they entered a nursing home.  Now today, most rehabilitation following surgery, strokes or general hospitalization happens in nursing homes for people over 55.

As we look back/reflect on this part of our careers, we are pleased to have been a part of the group of professionals who changed how healthcare was provided in the US. Our work extended care to millions of neglected older Americans warehoused in institutions. We improved their lives in terms of survival and opportunities to return home. In fact, you would be hard pressed to find a nursing home in the U.S., accepting Medicare dollars that does not have an SLP as part of their team. It has been our privilege to participate in this leap forward in service delivery to provide a better quality of life for our Nation’s most valuable living treasures: our parents and grandparents.

About the Authors

Marguerite Mullaney was born and raised in and around the Boston area. She continues to make her home in the Commonweath and rarely finds it necessary to travel beyond the 128 belt. Her undergraduate program was completed at Bridgewater State College and she attended Northeastern University for graduate school. Adult neurological disorders has been the primary focus of her clinical practice. Her vast knowledge of the field, thoughtful, pragmatic approach and incredible sense of humor have enlightened and inspired her patients, staff and colleagues for over 20 years.  Contact Marguerite at mullaneycccslp@comcast.net.

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.

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10s   by Gene Pizzolato, MS CCC-SLP

10s by Gene Pizzolato, MS CCC-SLP

1. Cookie of choice (for bedside swallow exams)
Lorna Doone

2. BDAE or WAB (for language testing)
BDAE

3. PICA +/- (for scoring)

+  Love the PICA!  In fact, I’ve used it for over 30 years with therapy plans and I call it a “Prompt-Cue Score” (PCS) system. After years of applying this format to my plans I considered it to be my own creation, until the PICA comparison was made by this web site’s Co-founder!. In any case my PCS provides me with great data to monitor progress.

4. Muppets or dwarves (for entertainment purposes only)

Muppets

4a. Favorite individual muppet

Fozzie Bear

5. Worst treatment moment of your career.

Medicaid Audit

6. Best advice you ever ignored.

“Don’t ever accept Medicaid payments”

7. Favorite, most reliable and practical treatment strategy.

I find that visual information organization strategies work well to support
information processing, comprehension and expressive language therapy.

8. Why SLP and not world domination?

Less stress

9. Would you do it all over again exactly the same way?

Absolutely not…… well maybe ….. actually “yes” with some adjustments.

 

10. What one thing do you still want to do before your career goals are completely achieved?

To organize my best therapy practices into a package that could be easily shared.

SHAMELESS SELF PROMOTION IN 30 WORDS (there actually is no word limit really so say whatever you want).

Gene Pizzolato, MS CCC SLP is a graduate of Columbia University and has been in private practice for 30 years. Specializing in working with school age children and adults with developmental disabilities, Gene has been a pioneer in the collaborative approach to treatment. Always a man of vision, Gene has been able to adapt his practice to meet the changing needs of the healthcare and school based communities as well as to continue to expand his clinical skills. As a mentor to countless students and new clinicians, Gene has entertained and inspired us as we endeavor to follow his lead.

Given this opportunity for shameless self-promotion, Gene would like to share with you some sage words of advice:

  1.  Be careful who you stand behind when scheduling your college courses, you may end up pursuing that line of study.
  2. If your business is based out of your home, a mudroom helps facilitate communication with itinerant therapists. You can leave them notes, schedules, reports, etc. And they can leave you cookies.
  3. Professional relationships, (all relationships, really) work best if they are based on mutual trust and respect.
  4. When asking for favors, it helps if you are charming and look like someone famous.

Contact Gene at: genepizz@gmail.com…

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Celebrating Differences

Celebrating Differences

In a status update on our Facebook page, I posted a quote form Arthur Helps (which I discovered through our Twitter feed– thank you disability.gov!):  “Wise sayings often fall on barren ground, but a kind word is never thrown away”.

I was going to use this as a stepping stone to get up on my soap box to remind one and all that it is often not our expertise, evidence based practice or academic platitudes that make the most difference to our patients, but our kindness and our understanding that has the biggest impact.

Then I went in search of Arthur Helps and discovered that Sir Arthur was educated at Eton and Cambridge, and served as Dean to the Privy Council during the reign of Queen Victoria. Then I discovered some more of his writings and had even more to think about.  In this political season and as many of us return to work after a summer break, these thoughts seem rather timely……

“In the first place, if people are to live happily together, they must not fancy, because they are thrown together now, that all their lives have been exactly similar up to the present time, that they started exactly alike, and that they are to be for the future of the same mind. A thorough conviction of the difference of men is the great thing to be assured of in social knowledge: it is to life what Newton’s law is to astronomy. Sometimes men have a knowledge of it with regard to the world in general: they do not expect the outer world to agree with them in all points, but are vexed at not being able to drive their own tastes and opinions into those they live with. Diversities distress them. They will not see that there are many forms of virtue and wisdom. Yet we might as well say, “Why all these stars; why this difference; why not all one star?”

“Many of the rules for people living together in peace, follow from the above. For instance, not to interfere unreasonably with others, not to ridicule their tastes, not to question and re-question their resolves, not to indulge in perpetual comment on their proceedings, and to delight in their having other pursuits than ours, are all based upon a thorough perception of the simple fact, that they are not we” (The Art of Living with Others, 1848).

They are not we.  I love that.  As people and professionals, we should embrace that.  All people have value.  All people are different.  We should celebrate those differences, seek common ground and work toward real solutions and optimal outcomes.  Forget platitiudes, name calling and blaming.  Of course, we must work from a sound knowledge base and within the scope of reality.  It would not be wise to embrace foolishness or danger, without recognizing and voicing the risks, but when we work diligently and cooperatively we can do great things.  Our actions and our kindness are what matters.  The rest is just “blah blah blah”.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.…

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Thank you!

Thank you!

I am standing on my soap box right now and shouting out a big THANK YOU! to anyone visiting or returning to our site. We have been away a while but we have not forgotten about you or our craft. We continue to toil every day in our jobs, often alone with little to no recognition. So I am here right one to say THANK YOU to you for all that you do. For all of the endless hours you spend working with your patients, and thinking about your patients, and planning your treatments. For all of the follow-up that you do with families and physicians and teachers and payors- thank you for all that goes unnoticed and unacknowledged. You deserve a pat on the back and probably more. But right now, my words will have to suffice.

I hope this site will help you find support and be a place for your voice. And if you are in a position to thank someone for their work or their help, please do so. We don’t hear enough of that as professionals (or probably as people). My colleague just started a new job. After her first few days, she was sincerely thanked by her boss for her efforts and the contributions she had already brought to the team. She was appreciative, but also realized that the last time she had been thanked for her work was when she worked for me, and that was 10 years ago! That’s a long time to go without recognition, wouldn’t you say?

So before you start that e-mail, or note, or conversation or performance review, remember to say thank you, the person on the receiving end has probably done something worthy of recognition and might be happy and likely much more cooperative if you noticed it.

About the author

Lisa Yauch-Cadden was born and raised in the Detroit, Michigan area. She has a Bachelor of Science degree in Biology and a Master’s in Speech Language Pathology from the University of Michigan. She has worked as an SLP in nearly all facets of the field: skilled nursing facilities, home care, acute care, transitional care, medical offices and schools. Throughout her career as a therapist, manager and business owner, Lisa has never strayed from providing direct line service, including state of the art evaluations using FEES/FEESST and MBS. While she needs no accolades to do her job, she is deserving of many. Her tireless efforts to advance the best clinical practices in Speech Language Pathology have changed lives for her patients, her clinical fellows, and those of us lucky enough to work with her on a regular basis. Contact Lisa at lycslp@gmail.com.…

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