Hospice eNews

What the Media Said about End-of-Life Care This Week

Week of April 18, 2005

…a service of Florida Hospices and Palliative Care

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OKLAHOMA EOL TASK FORCE ISSUES REPORT

 

            Last year, Attorney General Drew Edmondson convened a 16-member group, the Attorney General’s Task Force to Improve End-of-Life Care in Oklahoma.  They were charged to “find areas where the current system needed improvement, develop solutions and report its findings to those with the authority to make the changes,” Edmondson said.  Last week, the task group released its report, which says too many state residents die in institutions where their last wishes may be unknown or left unfulfilled.  It also says that more Oklahomans should die at home, in the care of hospice and with their last wishes carefully “spelled out in advance.” 

 

            The report calls for streamlining the system of end-of-life care; better communication between patients, family members and healthcare providers; better palliative care and the making of end-of-life decisions much earlier in life.  Other recommendations include:

            *  The creation of standard forms for physicians to use to document what kinds of care could or could not be provided at home or in hospices, hospitals or nursing homes;

            *  Courses in end-of-life and palliative care for licensed physicians;

            *  A new “uniform patient transfer form” which would go with patients from one institution to another and assure that their wishes in care are known;

            *  The implementation of hospital palliative care programs “extending through intensive care units to extended-care units” for both adults and children; and

            *  The use of quality improvement programs to measure several aspects of end-of-life care, including pain management and the use of advance directives.

 

            Oklahomans for Life, a group affiliated with the National Right to Life Committee, says that the report is “more concerned with facilitating accelerated death than with improving end-of-life care.”  Edmondson disagrees, saying that Oklahoma law “makes the presumption in favor of life, that people want to live and have all the necessary steps taken to preserve life … including artificial nutrition and hydration, if necessary.”  If they want something different, then they need to stipulate that, in the form of an advance directive, DNR order, or healthcare proxy. 

 

            The task force will continue its work for another year, funded by the attorney general’s revolving fund for consumer protection.  The full report is available from www.oag.state.ok.us.  Click on “End-of-Life Task Force Issues Final Report” and you will go to a page with the press release and PDF files.  (The Daily Oklahoman, 4/12; The Journal Record, 4/12; Tulsa World, 4/12; Oklahoma Attorney General’s Website)

TIPS FOR BILLING MEDICARE UNDER 2003 MODERNIZATION ACT

 

            Using the new billing code G0337, hospice medical directors can furnish evaluation and counseling services, but an Eli’s Home Care Week article says it isn’t easy.  Attorney Connie Raffa, of New York’s Arent Fox, says the benefit is a good thing, but “there are lots of different hoops to jump through to do it right.”

 

            CMS published a Medlearn Matters article about the issues, which can be found at www.cms.hhs.gov/medlearn/matters (scroll down to article MM3585).  Eli’s Home Care Week notes the following highlights:

            *  Pre-election evaluation and counseling, like the hospice benefit, require a six-month prognosis, but that prognosis does not have to be certified by the physician.  The referring physician must send a “determination of the terminal diagnosis,” but “actual certification of the terminal diagnosis is not required.”   John Mahoney, principal of the Summit Business Group in Penfield, NJ, says, “That a person be terminally ill with a prognosis of six months or less to obtain this consult benefit is an absurd restriction.”

            *  Payments by hospices to anyone in a position to refer patients to the hospice may trigger the Federal anti-kickback statute.  A hospice must have a medical director or other physician employee to use this service and problems may arise if the physician is employed part-time and gets extra compensation for the visits.

            *  If the hospice medical director is already the patient’s attending physician, the hospice cannot bill for G0337.

            *  “A medical director or other physician must be employed by the hospice to furnish this service, which the hospice bills the regional home health intermediary for…”

 

            The article offers tips to “stay on the right side of the anti-kickback statute with your medical director.”

            *  Have a detailed contract spelling out the services the medical director will perform.

            *  Be sure the physician documents the services he or she performs.

            *  Pay a fair market value for the services, which may mean determining what the fair market value is.

            *  Don’t overpay using G0337.  Raffa suggests paying the G0337 payment rate minus a fair-market value for administrative processing.  Be sure the details are spelled out in the contract.  (Eli’s Home Care Week, 4/11)

 

 

REPORTERS PRAISE HOSPICE

 

            Frank Davies, reporter for the Miami Herald, says, “The death of my mother three years ago was so intensely personal and wrenching that I expected never to write about it.  But the destructive rhetoric of fear and misrepresentation in the Terri Schiavo case has changed that.”  Davies worries that “some of the hysteria over Schiavo’s death has warped how people view hospice care and has made hard choices about life and death even more difficult for many families.”

 

            Davies writes that the news media picked up incorrect statements from politicians and activists, and “often reported these statements without questioning them, as if Schiavo’s final days in the Pinellas Park, Fla. Hospice were too dreadful to contemplate.  However, this was a travesty, and very harmful to people who might be considering hospice care for themselves or a relative.  I know from personal experience,” he said, “as hundreds of thousands of others know, that hospice care can be a blessing.”

 

            Davies says that there is “plenty of evidence of some good news in the Schiavo case.”  People are talking about end-of-life issues and making advance directives and powers of attorney.  “But the bad news,” he wrote, “is that hospices took a hit in some of the outlandish rhetoric that characterized the Schiavo debate.  When you hear hospices called ‘death factories’ on cable TV and listen to politicians compare Schiavo’s death to that of starving African children, it takes a toll.” 

 

            Davies quotes J. Donald Schumacher, head of NHPCO, as saying, “There was so much harsh, inappropriate language, and it was just inaccurate.”  Davies also cites Arthur Caplan, director of the University of Pennsylvania’s Center for Bioethics, as saying, “those who suggested that any hospice would ever let a person die a miserable, painful death should simply recant.” Davies concludes by saying that “death in a hospice is not inhumane.  It’s one of the most humane ways to die.  Thousands of people know that from firsthand experience, and it’s time for people who know the truth to speak out.” 

 

            Jacqueline Salmon wrote an article for The Washington Post, entitled “Hospices Dedicated to Easing Final Days; Dying Patients and Their Families Appreciate Specialized Care Given at Home.”  Salmon’s article focuses on the benefits of hospice and the financial realities and issues involved in offering hospice care.  (The Miami Herald, 4/11; Chattanooga Times Free Press, 4/17; The Washington Post, 4/14) 

 

 

ARTICLE OFFERS TIPS ON COMPLETING ADVANCE DIRECTIVES

 

            An article in Home Health Line offers tips, based on readers’ feedback on a survey, about ways to get more patients to complete advance directives.  Most of the suggestions are basic and simple and respondents’ feedback highlights how other activities and needs often overshadow the need for working on advance directives.  Some of the tactics and tips are:

            *  Get patients to paraphrase information about advance directives to make sure they actually understand. 

            *  Send a social worker back, at a separate visit, to work on advance directives.

            *  Provide written and verbal information, ask the patients to discuss it with their families and then offer to send a social worker out to discuss it.  One agency says that, by taking this approach, more than 70% of their patients eventually complete advance directives, compared to about 30% nationwide. 

            *  Provide FAQ sheets.

            * “Initiate the conversation this way:  ‘Do you have anything in writing that tells your doctor or family what you want done if you stop breathing or your heart stops beating?’”

            *  Use Terri Schiavo’s experience as a springboard for opening the discussion. 

             “One thing is certain,” says the article.  “Clinicians must do more than simply provide written materials to patients about formulating advance directives.”  (Home Health Line, 4/8)

PUBLIC POLICY NOTES

 

            *  California’s Assembly Judicial Committee last week approved Assembly Bill 654, which would allow physician-assisted suicide.  The bill, which passed by a 5-4 vote, is patterned after Oregon’s Death With Dignity Act.  The bill must pass the Assembly Appropriations Committee and the full Assembly and Senate before being sent for the governor’s signature.  (Modesto Bee, 4/13; Los Angeles Times, 4/13)

 

            *  The Vermont House Human Services Committee held hearings on Vermont’s proposed death-with-dignity bill.  Speakers as diverse as farmers, laborers, physicians and a former governor told the committee what they would like to see enacted.  Observers say that the law is unlikely to pass this year.  (AP, 4/12)

 

            *  Vermont Lieutenant Governor Brian Dubie (R) issued a press release expressing concern about the state’s proposed legislation to allow physician-assisted suicide.  Dubie invited representatives of the Vermont Center for Independent Living, a non-profit organization promoting the rights of disabled citizens, to his office to share their concerns  (US Fed News, 4/13)

 

            *  Missouri Governor Matt Blunt (R) got legislative approval of his plan to cut many services from the state Medicaid program, including hospice care for dying patients.  The plan also allows elimination of care for many elderly and disabled in years when there is insufficient state revenue to support those services.  (The Kansas City Star, 4/8)

 

            *  France’s legislature approved a law last week that allows terminally ill patients to refuse treatment that would keep them alive, but the law does not legalize euthanasia.  Families may end life support for comatose patients and doctors may prescribe pain medication for terminally ill patients even if death is hastened by doing so.  Doctors may not, even at the patient’s request, end a patient’s life, even if there is no hope of recovery.  (The New York Times, 4/14)

 

            *  A Washington Times article reported that several states have bills aiming to “avoid a recurrence of the seven-year end-of-life dispute among family members” of Terri Schiavo.  Michigan is considering prohibiting a married spouse involved in an extramarital relationship from denying food, fluids or medical treatment necessary to sustain life from a disabled spouse.  Other states may prohibit removal of feeding tubes when family members cannot agree that removal is the best course.  (American Health Line, 4/12)

 

 

HOSPICE NOTES

 

            *  More than 600 guests attended the NHPCO annual gala in celebration of “40 years of modern hospice care.”  Senator Hillary Rodham Clinton (D-New York), a sponsor of legislation on advance directives, presented an award to former HHS Secretary Joe Califano, who made hospice care a Medicaid benefit during the Carter administration.  Representatives of The Hospice of the Florida Suncoast, where Terri Schiavo lived for 15 years, received a standing ovation from other attendees.  (The Washington Post, 4/11)

 

            *  An Alabama judge has had an 81-year-old Georgia woman removed from hospice and transferred to UAB Hospital.  Mae Magouirk’s legal guardian is her granddaughter, who placed her grandmother in hospice on the advice of several physicians.  Other family members objected and the case went to court.  The judge ordered a panel of doctors to decide what kind of care Magouirk should have.  A decision was made to airlift Magouirk to UAB, where she is now in critical care.  (Birmingham News, 4/12)

 

            *  Federal regulators are investigating whether Chemed Corp., through Vitas Healthcare Corp., improperly billed for Medicare and Medicaid services over the past eight years.  Kevin McNamara, chief executive officer for Chemed, said, “Vitas is fully cooperating with the OIG in this investigation.”  (AP, 4/8)

 

 

OTHER NOTES

 

            *  Ira Flatow, host of NPR’s Talk of the Nation/Science Friday, recently interviewed several experts about the issues arising from the Schiavo case.  The transcript is online at www.npr.org/templates/story/story.php?storyId=4583139.  (NPR’S Talk of the Nation, 4/8)

 

            *  Two case studies, published in the February issue of the Journal of Palliative Medicine, report on the use of controlled sedation to alleviate symptoms at the end of life.  University of Rochester researchers defined controlled sedation as “the use of medication to bring a patient to the point of unconsciousness to relieve intolerable suffering before death, but not to hasten or bring about death.”  (Medical Device Business Week, 4/20)

 

            *  Dr. William E. Hurwitz, recently convicted of drug trafficking, was sentenced to 15 years in prison.  The article reports that 21% of Hurwitz’s patients had criminal records and that at least one patient had a prescription for 1,600 OxyContin pills a day.  (AP, 4/14)

 

            *  A Money article encourages people to make both living wills and durable healthcare powers of attorney.  The author quotes attorney Albin Renauer, co-author of Quicken WillMaker, as saying that the living will provides instructions to your doctor, while the power of attorney is to “designate a trusted advocate to ensure your wishes are carried out.”  (Money, 5/2005)

 

            *  A Charlotte Observer writer says, “Life-and-death decisions once made by nature are more and more often being made by relatives.  In the future, they may be made by strangers for whom a patient’s wishes are only one consideration – and maybe not the dominant one.”  Increasing longevity will bring additional problems and a big issue will be the cost of long-term care at the end of life.  (Charlotte Observer, 4/10)