- Email: [email protected]
Octreotide for Control of Bleeding Peristomal Varices in Palliative Care
e2
Letters
by the paperwork to facilitate the hospice transferd time that would better be spent at the bedside addressing symptoms and offering education and support. All these issues are magnified in teaching hospitals because of the added layer of various levels of clinicians in training. For hospitals, unless the work processes are exquisitely defined and agreed on, there is often confusion about ‘‘who does what’’ between the hospital and hospice staff. Second, the process of patient discharge and readmission is costlydhospital staff must devote time and resources to manage the electronic medical record requirements, to counsel patients and families on the care transition, and to engage in handoffs to the hospice team. For hospices that are already struggling with short lengths of stay, a large bolus of short-stay patients could worsen finances because of the burden of providing high-cost care for a short period. Finally, a robust palliative care team should be capable of meeting patient and family needs through the inpatient dying process; thus, palliative care staff may view hospice resources as redundant, especially if the endof-life care environment remains unchanged. In discussions with colleagues, many hospitals and health systems have started partnership models with regional hospices to reduce inpatient mortality rates. One could imagine this could lead to a redirection of hospice resources from patients’ homes and freestanding hospice facilities to acute care hospitals. Worse, patient safety issues contributing to elevated inpatient mortality rates could be missed or ignored, as hospice flipping is used to cloak more difficult-tosolve inpatient care issues. In a new health care era, wherein clinicians are often employed by health care institutions and perhaps apprehensive to advocate for patient interests if in conflict with hospital administration goals, it is incumbent on palliative care clinicians to put the patient and family first in making these care decisions. When transition to inpatient hospital hospice services is the best option to meet a patient or family need, then we should help facilitate this process. But let us keep our priorities aligned with the foundational principles of hospice and palliative medicine, and avoid ‘‘treating for the test.’’ Sean Marks, MD Medical College of Wisconsin Milwaukee, Wisconsin, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.10.009
References 1. Barbieri JS, Fuchs BD, Fishman N, et al. The Mortality Review Committee: a novel and scalable approach to reducing
Vol. 49 No. 3 March 2015
inpatient mortality. Jt Comm J Qual Patient Saf 2013;39: 387e395. 2. Zheng NT, Mukamel DB, Friedman B, Caprio TV, Temkin-Greener H. The effect of hospice on hospitalizations of nursing home residents. J Am Med Dir Assoc 2014 Oct 7; [Epub ahead of print]. 3. Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: consensus recommendations. J Palliat Med 2011;14:1e7. 4. Weissman DE. Next gen palliative care. J Palliat Med 2012;15:2e4.
Octreotide for Control of Bleeding Peristomal Varices in Palliative Care To the Editor: Palliative care practitioners are often called on to manage difficult symptom issues where the primary focus is quality of life over aggressive interventions. One rare but potentially troubling management issue is bleeding from peristomal varices in patients nearing end of life. Such situations may arise in the setting of prior stoma formation for treatment of conditions such as bowel obstruction or colon cancer where the patient also has portal hypertension from underlying comorbidities or complications of their metastatic disease. The result can be refractory bleeding necessitating emergency room visits, admissions, and transfusions. Various approaches have been advocated in general for peristomal varices including embolization,1 transjugular intrahepatic portosystemic shunts (TIPS),2,3 other surgical shunts, or even liver transplantation.2 For the patient nearing end of life, however, these would rarely be appropriate. We describe two cases of peristomal variceal bleeding successfully controlled with the administration of subcutaneous (SC) octreotide, which was continued to end of life with excellent control of bleeding.
Case 1 Patient 1 was a 52-year-old woman with metastatic sigmoid adenocarcinoma, presenting with liver and adnexal metastases as well as omental caking at diagnosis. Chemotherapy provided good disease control for nine months at which point she was admitted with a large bowel obstruction from her primary sigmoid tumor. This was treated operatively with a diverting ostomy after conservative medical therapy failed, and chemotherapy was resumed postoperatively. She did well for a further 15 months when there was evidence of disease progression, predominately in the
Vol. 49 No. 3 March 2015
Letters
liver. A clinical trial medication was initiated but was poorly tolerated and stopped after two cycles. At this point, she was noted to have extensive involvement of all lobes of her liver. One month later, she began to notice oozing of bright red blood from her stoma. A small peristomal bleeding site was treated with silver nitrate; however, she had a more major bleed one month later. Endoscopy revealed no site of bleeding, but she was noted to have peristomal varices believed to be secondary to her extensive liver disease and presumed portal hypertension. The patient continued to bleed and required transfusion support. Surgical therapy was ruled out, and local therapies to control the bleeding, including repeated attempts with silver nitrate and close examination of stomal appliances, were unsuccessful. The patient had been followed in the palliative care clinic for some time for symptom management. The ongoing bleeding was a source of significant distress for both patient and family, particularly from the sense of hopelessness over the lack of a definitive method of control. Whereas there was no clear demonstration of portal hypertension, drawing on the parallel with bleeding gastric/esophageal varices, a decision was made in concert with the patient to empirically embark on a trial of octreotide therapy. The initial SC octreotide dose of 500 mg twice a day was chosen to minimize the number of injections per day (vs. three-times-a-day dosing), maximize the chance of efficacy, and determine the minimum effective dose, with the intention of reducing the dose if bleeding improved. The patient noted near complete cessation of bleeding within 48 hours of starting octreotide, but because of reluctance to have bleeding resume, did not wish to lower her dose at any point. Over the ensuing two months until her death, she remained on regular twice daily dosing and had no further major bleeding, although intermittently noted a small amount of oozing of blood, which readily responded to local pressure. She had no side effects from the octreotide administration.
Case 2 Patient 2 was a 70-year-old woman diagnosed with metastatic colorectal cancer treated with a diverting loop ostomy for near obstruction followed by chemotherapy for more than 3.5 years, at which point her regimen was switched because of progression of her liver metastases. After six months on the new regimen, she developed peristomal bleeding. At that time, she
e3
was noted to have extensive liver involvement as well as adnexal metastases, peritoneal nodularity, and adenopathy. Past medical history was notable for primary biliary cirrhosis. The onset of peristomal bleeding resulted in hospital admission, although settled with conservative care. Her recent chemotherapy had included bevacizumab, which was discontinued as it was felt to be a possible etiologic factor.4 However, two weeks later, she had more significant stomal bleeding prompting readmission and transfusion of four units of packed red blood cells. Upper endoscopy and ileoscopy showed no site of bleeding, but she was noted to have peristomal varices. Given the recent success described in Case 1, she was referred to the palliative care clinic for consideration of octreotide, which was started, as in Case 1, at 500 mg SC twice a day. Over the ensuing months, she had no bleeding while on octreotide but would start to bleed shortly after it was weaned and stopped, generally within one to two weeks of its cessation. The bleeding remained mild (no further transfusions) and was promptly aborted with reinitiation of octreotide. Ultimately, she was maintained on a routine of selfadministered SC octreotide at doses of 250e500 mg twice a day for one week any time bleeding was noted. As she preferred to have periods off the injections, once the bleeding settled, she would stop the medication until she next noted bleeding (maximum time off of two weeks). She was offered but declined the long-acting octreotide formulation, preferring the intermittent SC option. She ultimately died of her underlying cancer several months later, with no further significant bleeding episodes, and having tolerated the octreotide with no noted side effects.
Comment Within palliative care, octreotide is best known for its use in management of malignant bowel obstructions because of its antisecretory effects,5 but it also is used in a variety of other conditions including neuroendocrine tumors, bronchorrhea, enterocutaneous fistulas, intractable diarrhea, and bleeding from esophageal varices.6,7 Its role in the management of variceal bleeds prompted its trial in our cases. Octreotide is a synthetic form of somatostatin (SST), a naturally occurring hormone that has a wide array of physiologic actions. Somatostatin inhibits the secretion of growth hormone but also the release of a number of peptides, particularly in the gastrointestinal system.7 Octreotide, as a synthetic derivative, has a longer half-life than native SST and is available
e4
Letters
as an immediate-release injection administered SC two or three times a day, as well as an intramuscular depot injection given monthly. The drug is generally well tolerated, with injection site irritation as the most common adverse effect. Octreotide acts on splanchnic blood flow by causing vasoconstriction via inhibition of nitric oxide synthesis and inhibition of glucagon release, both of which cause splanchnic vasodilation.7 The resulting fall in splanchnic blood flow is felt to be responsible for reducing portal pressures and thereby reducing variceal bleeding8 as a bridge to more definitive therapy. Octreotide also has been suggested to have utility in the management of bleeding from gastrointestinal angiodysplasia, again in part related to its vasoactive mechanism in addition to inhibition of angiogenesis and possibly improved platelet aggregation.9,10 This effect is reported in the absence of portal hypertension, and although both our patients had disease that may have increased portal pressures and had demonstrable varices, we did not specifically demonstrate portal hypertension in either. In our patients, endoscopy failed to reveal a specific site of bleeding, rendering techniques such as embolization or local cauterization ineffective, and, given the advanced nature of their illnesses, aggressive therapy such as a TIPS procedure was not considered. For both, the bleeding caused marked psychosocial distress, and both had required transfusion support before initiation of octreotide. Given the observed effectiveness of octreotide for these patients, its lack of significant side effects, and its broad application in palliative care, we suggest it be considered for patients for whom noninterventional care is appropriate in the setting of peristomal bleeding varices. Debbie Selby, MD Lawrence D. Jackson, BScPhm Sunnybrook Health Sciences Center Toronto, Ontario, Canada E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.12.001
References 1. Kwok A, Wang F, Maher R, et al. The role of minimally invasive percutaneous embolization technique in the management of bleeding stomal varices. J Gastrointest Surg 2013;17:1327e1330. 2. Spier B, Gayyad A, Lucey M, et al. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008;6:346e352. 3. Deipolyi A, Kalva S, Oklu R, et al. Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices. AJR Am J Roentgenol 2014;203:668e673.
Vol. 49 No. 3 March 2015
4. AVASTINÒ monograph. Revised June 27, 2014. Mississauga, ON: Hoffmann-La Roche Limited. Available at: www.rochecanada.com. Last accessed November 23, 2014. 5. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer 2000;8:188e191. 6. Murphy E, Prommer E, Mihalyo M, Wilcock A. Octreotide. J Pain Symptom Manage 2010;40:142e148. 7. Chan M, Chan M, Mengshol J, Fish D, Chan E. Octreotide: a drug often used in the critical care setting but not well understood. Chest 2013;144:1937e1945. 8. Wells M, Chande N, Adams P, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012;35: 1267e1278. 9. Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010;55:2129e2134. 10. Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia-pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2013;39: 15e34.
Re: The Sidney ProjectÔ To the Editor: We were moved by the article ‘‘Reflections on the Sidney ProjectÔ: Can We talk? Can We Give Voice to the Taboo Topics That Are Usually Not Embraced in Residency Medical Education?’’ by Janet Lynn Roseman.1 Dr. Roseman was quite open about the death of her father, Sidney, and that this death occurred ‘‘at the hands of a wounded medical culture . that refused to acknowledge that his life was not worth saving.’’1(p. 478) What a wonderful compliment to her father and his legacy by establishing the Sidney Project. We also congratulate Dr. Roseman for expanding the project from just 16 residents to many moredand not just in psychiatry. We, too, value a safe place where residents can share their work experiences and specifically, the affective side of this work, as they learn an immense amount of knowledge and try to keep pace with high patient volume and severity of illness. In palliative care and in internal medicine, in general, there are multiple venues for providers at all stages in their careers to learn more about and, in some instances, share with other house officers in a safe environment, the toll of their work. We all participate in ‘‘G Briefing’’ at Dukedvoluntary forums facilitated by a senior palliative care clinician, ‘‘Dr. G,’’ and an experienced clinical social workerdwhere internal
Letters
by the paperwork to facilitate the hospice transferd time that would better be spent at the bedside addressing symptoms and offering education and support. All these issues are magnified in teaching hospitals because of the added layer of various levels of clinicians in training. For hospitals, unless the work processes are exquisitely defined and agreed on, there is often confusion about ‘‘who does what’’ between the hospital and hospice staff. Second, the process of patient discharge and readmission is costlydhospital staff must devote time and resources to manage the electronic medical record requirements, to counsel patients and families on the care transition, and to engage in handoffs to the hospice team. For hospices that are already struggling with short lengths of stay, a large bolus of short-stay patients could worsen finances because of the burden of providing high-cost care for a short period. Finally, a robust palliative care team should be capable of meeting patient and family needs through the inpatient dying process; thus, palliative care staff may view hospice resources as redundant, especially if the endof-life care environment remains unchanged. In discussions with colleagues, many hospitals and health systems have started partnership models with regional hospices to reduce inpatient mortality rates. One could imagine this could lead to a redirection of hospice resources from patients’ homes and freestanding hospice facilities to acute care hospitals. Worse, patient safety issues contributing to elevated inpatient mortality rates could be missed or ignored, as hospice flipping is used to cloak more difficult-tosolve inpatient care issues. In a new health care era, wherein clinicians are often employed by health care institutions and perhaps apprehensive to advocate for patient interests if in conflict with hospital administration goals, it is incumbent on palliative care clinicians to put the patient and family first in making these care decisions. When transition to inpatient hospital hospice services is the best option to meet a patient or family need, then we should help facilitate this process. But let us keep our priorities aligned with the foundational principles of hospice and palliative medicine, and avoid ‘‘treating for the test.’’ Sean Marks, MD Medical College of Wisconsin Milwaukee, Wisconsin, USA E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.10.009
References 1. Barbieri JS, Fuchs BD, Fishman N, et al. The Mortality Review Committee: a novel and scalable approach to reducing
Vol. 49 No. 3 March 2015
inpatient mortality. Jt Comm J Qual Patient Saf 2013;39: 387e395. 2. Zheng NT, Mukamel DB, Friedman B, Caprio TV, Temkin-Greener H. The effect of hospice on hospitalizations of nursing home residents. J Am Med Dir Assoc 2014 Oct 7; [Epub ahead of print]. 3. Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: consensus recommendations. J Palliat Med 2011;14:1e7. 4. Weissman DE. Next gen palliative care. J Palliat Med 2012;15:2e4.
Octreotide for Control of Bleeding Peristomal Varices in Palliative Care To the Editor: Palliative care practitioners are often called on to manage difficult symptom issues where the primary focus is quality of life over aggressive interventions. One rare but potentially troubling management issue is bleeding from peristomal varices in patients nearing end of life. Such situations may arise in the setting of prior stoma formation for treatment of conditions such as bowel obstruction or colon cancer where the patient also has portal hypertension from underlying comorbidities or complications of their metastatic disease. The result can be refractory bleeding necessitating emergency room visits, admissions, and transfusions. Various approaches have been advocated in general for peristomal varices including embolization,1 transjugular intrahepatic portosystemic shunts (TIPS),2,3 other surgical shunts, or even liver transplantation.2 For the patient nearing end of life, however, these would rarely be appropriate. We describe two cases of peristomal variceal bleeding successfully controlled with the administration of subcutaneous (SC) octreotide, which was continued to end of life with excellent control of bleeding.
Case 1 Patient 1 was a 52-year-old woman with metastatic sigmoid adenocarcinoma, presenting with liver and adnexal metastases as well as omental caking at diagnosis. Chemotherapy provided good disease control for nine months at which point she was admitted with a large bowel obstruction from her primary sigmoid tumor. This was treated operatively with a diverting ostomy after conservative medical therapy failed, and chemotherapy was resumed postoperatively. She did well for a further 15 months when there was evidence of disease progression, predominately in the
Vol. 49 No. 3 March 2015
Letters
liver. A clinical trial medication was initiated but was poorly tolerated and stopped after two cycles. At this point, she was noted to have extensive involvement of all lobes of her liver. One month later, she began to notice oozing of bright red blood from her stoma. A small peristomal bleeding site was treated with silver nitrate; however, she had a more major bleed one month later. Endoscopy revealed no site of bleeding, but she was noted to have peristomal varices believed to be secondary to her extensive liver disease and presumed portal hypertension. The patient continued to bleed and required transfusion support. Surgical therapy was ruled out, and local therapies to control the bleeding, including repeated attempts with silver nitrate and close examination of stomal appliances, were unsuccessful. The patient had been followed in the palliative care clinic for some time for symptom management. The ongoing bleeding was a source of significant distress for both patient and family, particularly from the sense of hopelessness over the lack of a definitive method of control. Whereas there was no clear demonstration of portal hypertension, drawing on the parallel with bleeding gastric/esophageal varices, a decision was made in concert with the patient to empirically embark on a trial of octreotide therapy. The initial SC octreotide dose of 500 mg twice a day was chosen to minimize the number of injections per day (vs. three-times-a-day dosing), maximize the chance of efficacy, and determine the minimum effective dose, with the intention of reducing the dose if bleeding improved. The patient noted near complete cessation of bleeding within 48 hours of starting octreotide, but because of reluctance to have bleeding resume, did not wish to lower her dose at any point. Over the ensuing two months until her death, she remained on regular twice daily dosing and had no further major bleeding, although intermittently noted a small amount of oozing of blood, which readily responded to local pressure. She had no side effects from the octreotide administration.
Case 2 Patient 2 was a 70-year-old woman diagnosed with metastatic colorectal cancer treated with a diverting loop ostomy for near obstruction followed by chemotherapy for more than 3.5 years, at which point her regimen was switched because of progression of her liver metastases. After six months on the new regimen, she developed peristomal bleeding. At that time, she
e3
was noted to have extensive liver involvement as well as adnexal metastases, peritoneal nodularity, and adenopathy. Past medical history was notable for primary biliary cirrhosis. The onset of peristomal bleeding resulted in hospital admission, although settled with conservative care. Her recent chemotherapy had included bevacizumab, which was discontinued as it was felt to be a possible etiologic factor.4 However, two weeks later, she had more significant stomal bleeding prompting readmission and transfusion of four units of packed red blood cells. Upper endoscopy and ileoscopy showed no site of bleeding, but she was noted to have peristomal varices. Given the recent success described in Case 1, she was referred to the palliative care clinic for consideration of octreotide, which was started, as in Case 1, at 500 mg SC twice a day. Over the ensuing months, she had no bleeding while on octreotide but would start to bleed shortly after it was weaned and stopped, generally within one to two weeks of its cessation. The bleeding remained mild (no further transfusions) and was promptly aborted with reinitiation of octreotide. Ultimately, she was maintained on a routine of selfadministered SC octreotide at doses of 250e500 mg twice a day for one week any time bleeding was noted. As she preferred to have periods off the injections, once the bleeding settled, she would stop the medication until she next noted bleeding (maximum time off of two weeks). She was offered but declined the long-acting octreotide formulation, preferring the intermittent SC option. She ultimately died of her underlying cancer several months later, with no further significant bleeding episodes, and having tolerated the octreotide with no noted side effects.
Comment Within palliative care, octreotide is best known for its use in management of malignant bowel obstructions because of its antisecretory effects,5 but it also is used in a variety of other conditions including neuroendocrine tumors, bronchorrhea, enterocutaneous fistulas, intractable diarrhea, and bleeding from esophageal varices.6,7 Its role in the management of variceal bleeds prompted its trial in our cases. Octreotide is a synthetic form of somatostatin (SST), a naturally occurring hormone that has a wide array of physiologic actions. Somatostatin inhibits the secretion of growth hormone but also the release of a number of peptides, particularly in the gastrointestinal system.7 Octreotide, as a synthetic derivative, has a longer half-life than native SST and is available
e4
Letters
as an immediate-release injection administered SC two or three times a day, as well as an intramuscular depot injection given monthly. The drug is generally well tolerated, with injection site irritation as the most common adverse effect. Octreotide acts on splanchnic blood flow by causing vasoconstriction via inhibition of nitric oxide synthesis and inhibition of glucagon release, both of which cause splanchnic vasodilation.7 The resulting fall in splanchnic blood flow is felt to be responsible for reducing portal pressures and thereby reducing variceal bleeding8 as a bridge to more definitive therapy. Octreotide also has been suggested to have utility in the management of bleeding from gastrointestinal angiodysplasia, again in part related to its vasoactive mechanism in addition to inhibition of angiogenesis and possibly improved platelet aggregation.9,10 This effect is reported in the absence of portal hypertension, and although both our patients had disease that may have increased portal pressures and had demonstrable varices, we did not specifically demonstrate portal hypertension in either. In our patients, endoscopy failed to reveal a specific site of bleeding, rendering techniques such as embolization or local cauterization ineffective, and, given the advanced nature of their illnesses, aggressive therapy such as a TIPS procedure was not considered. For both, the bleeding caused marked psychosocial distress, and both had required transfusion support before initiation of octreotide. Given the observed effectiveness of octreotide for these patients, its lack of significant side effects, and its broad application in palliative care, we suggest it be considered for patients for whom noninterventional care is appropriate in the setting of peristomal bleeding varices. Debbie Selby, MD Lawrence D. Jackson, BScPhm Sunnybrook Health Sciences Center Toronto, Ontario, Canada E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.12.001
References 1. Kwok A, Wang F, Maher R, et al. The role of minimally invasive percutaneous embolization technique in the management of bleeding stomal varices. J Gastrointest Surg 2013;17:1327e1330. 2. Spier B, Gayyad A, Lucey M, et al. Bleeding stomal varices: case series and systematic review of the literature. Clin Gastroenterol Hepatol 2008;6:346e352. 3. Deipolyi A, Kalva S, Oklu R, et al. Reduction in portal venous pressure by transjugular intrahepatic portosystemic shunt for treatment of hemorrhagic stomal varices. AJR Am J Roentgenol 2014;203:668e673.
Vol. 49 No. 3 March 2015
4. AVASTINÒ monograph. Revised June 27, 2014. Mississauga, ON: Hoffmann-La Roche Limited. Available at: www.rochecanada.com. Last accessed November 23, 2014. 5. Mercadante S, Ripamonti C, Casuccio A, Zecca E, Groff L. Comparison of octreotide and hyoscine butylbromide in controlling gastrointestinal symptoms due to malignant inoperable bowel obstruction. Support Care Cancer 2000;8:188e191. 6. Murphy E, Prommer E, Mihalyo M, Wilcock A. Octreotide. J Pain Symptom Manage 2010;40:142e148. 7. Chan M, Chan M, Mengshol J, Fish D, Chan E. Octreotide: a drug often used in the critical care setting but not well understood. Chest 2013;144:1937e1945. 8. Wells M, Chande N, Adams P, et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012;35: 1267e1278. 9. Brown C, Subramanian V, Wilcox CM, Peter S. Somatostatin analogues in the treatment of recurrent bleeding from gastrointestinal vascular malformations: an overview and systematic review of prospective observational studies. Dig Dis Sci 2010;55:2129e2134. 10. Sami SS, Al-Araji SA, Ragunath K. Review article: gastrointestinal angiodysplasia-pathogenesis, diagnosis and management. Aliment Pharmacol Ther 2013;39: 15e34.
Re: The Sidney ProjectÔ To the Editor: We were moved by the article ‘‘Reflections on the Sidney ProjectÔ: Can We talk? Can We Give Voice to the Taboo Topics That Are Usually Not Embraced in Residency Medical Education?’’ by Janet Lynn Roseman.1 Dr. Roseman was quite open about the death of her father, Sidney, and that this death occurred ‘‘at the hands of a wounded medical culture . that refused to acknowledge that his life was not worth saving.’’1(p. 478) What a wonderful compliment to her father and his legacy by establishing the Sidney Project. We also congratulate Dr. Roseman for expanding the project from just 16 residents to many moredand not just in psychiatry. We, too, value a safe place where residents can share their work experiences and specifically, the affective side of this work, as they learn an immense amount of knowledge and try to keep pace with high patient volume and severity of illness. In palliative care and in internal medicine, in general, there are multiple venues for providers at all stages in their careers to learn more about and, in some instances, share with other house officers in a safe environment, the toll of their work. We all participate in ‘‘G Briefing’’ at Dukedvoluntary forums facilitated by a senior palliative care clinician, ‘‘Dr. G,’’ and an experienced clinical social workerdwhere internal