Hospice eNews
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What the Media Said about End-of-Life Care This Week
Week of
May 23, 2005
…a
service of
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STATE OF AGING
The
State of Aging and Health in America 2004, funded by The Merck
Institute of Aging and Health (MIAH), the CDC and the Gerontological Society of
America (GSA), was recently
released. The report contains state- and
national-based report cards on 15 key indicators of health of senior
adults. The report then compares these
to the targets outlined in Healthy People
2000, a strategy prepared by the Department of Health and Human
Services in 1990 for improving the health of US adults by the end of the
century. The
report issues calls to action on each of the key indicators and puts spotlights
on physical activity and the
The report contains a number of items
specifically related to pain, chronic disease and quality of life in
seniors. Among the facts presented are:
* At
least 80% of
* Diabetes currently affects 20% of persons aged 65 or older and the number of adults over 75 with diabetes is expected to quadruple to 4 million by 2050.
* Chronic diseases are “a major contributor to health care costs” and two-thirds of current costs go to the treatment of chronic illness. For older Americans, it’s 95%. Alzheimer’s disease costs Medicare and Medicaid $50 billion each year.
* Chronic diseases reduce the quality of life of older adults. Only 25% of those over 85 report very good or excellent health, compared to 43% of those 65 or older. Race is also a factor, with 40% of whites and 25% of blacks over 65 reporting very good or excellent health.
“The tragedy of the leading chronic disease killers is that they are often preventable,” the report says. “Although the risk of disease and disability clearly increases with age, poor health is not an inevitable consequence of aging.” Among the report’s recommendations for chronic disease risk reduction are regular physical activity, non-smoking lifestyle, healthy diet and regular health screenings.
The American healthcare workforce is not ready for the aging of the population, the report says. In 2012, nearly 10,000 Americans a day will turn 65 and by 2030 one-fifth of the population will be over 65. The authors of the report write that the healthcare workforce has insufficient training to provide “appropriate care” and there are too few providers with specialized training in geriatrics. “Moreover, there is a gap between what many primary care providers know, and what they need to know, to optimally treat older patients.”
The report’s “call to action”
recommendations include an increase in training funds, new research, new
practices for achieving change, recruitment of more healthcare workers into
geriatrics, better geriatric education in healthcare settings and enhancement
of the skills of community practitioners.
Several states were singled out for
creative approaches to improving the health of their senior citizens. ElderCount, in
The PDF file of the report can be downloaded from www.cdc.gov/aging/, the CDC website or the MIAH website, www.miahonline.org. (CDC Website; MIAH Website; PainAdvocacyCommunity, 5/2005)
JAMA EXAMINES ETHICS, THE CONSTITUTION, AND DYING
Lawrence O. Gostin, JD, of the Georgetown
University Law Center, uses the Terri Schiavo case to examine several points of
ethics and law as they relate to dying persons. In “
Ethics, the Constitution, and the
Dying Process: The Case of Theresa Marie Schiavo,” Gostin sets
aside the politics of the case and focuses on four issues of special
concern: 1) the lack of factual and
medical clarity; 2) withdrawal of nutrition and hydration; 3) decision making;
and 4) implications for the disabled and elderly.
Gostin says, “The public appeared most troubled by the sharply divergent perspectives relating to facts and medical diagnosis.” With family members, politicians, commentators and others weighing in with opposing views, should we, Gostin asks, do as President Bush suggested and “err on the side of life?” To do so, he says, is to “deny an equally important value – the autonomy of the person and her constitutional right to decline life-sustaining treatment.” The only appropriate course, Gostin says, is to “rely on the judicial process and the rule of law.” Schiavo’s guardian ad litem observed, “Sometimes good law is not enough, good medicine is not enough, and all too often, good intentions do not suffice. Sometimes, the answer is in the process, not the presumed outcome. We must be left with the hope that the right thing will be done well.”
Gostin examines the “moral and legal significance” of nutrition and hydration, saying that Pope John Paul II underscored the “ordinary” quality of sustenance in maintaining human life. But despite the emotional overtones, Gostin says that it is “hard to perceive a material moral distinction between artificial nutrition and hydration and other medical interventions that are just as crucial to sustaining life, such as respiration.” Most, but not all, bioethicists and professional associations approve of withholding food and hydration according to a person’s wishes.
Gostin says that the weight of the law is firmly on the side of the family, rather than the government, in making decisions for patients. The New Jersey Supreme Court wrote, “This tradition of respect and confidence in the family should ground our approach to the treatment of the sick.” Justice Brennan, in the Nancy Cruzan case, asked, “Is there any reason to suppose that a state is more likely to make the choice that the patient would have made than someone who knew the patient intimately? To ask the question is to answer it.”
Speaking to the issue of those with disabilities, Gostin says that “society risks creating two opposite errors: treading on liberty by imposing invasive treatment against a person’s previously expressed wishes and disrespecting human life by withholding necessary care and treatment for a person with a disability.” Other factors enter in, such as underlying medical conditions, and cost.
In conclusion, Gostin recommends renewed emphasis on advance directives; counseling and mediation to help families “come to consensus and find peace”; providing services and promoting public attitudes which support persons with disabilities, and offering palliative care to people in the dying process. (JAMA, 2005;293:2403-2407)
RESEARCH AND RESOURCE NOTES
* New
research has found that persons over 60 report greater pain relief from
morphine-based painkillers than younger people do and that they are less likely
to require “rapidly escalating doses” for pain control. The
* The
American Heart Association and the
* The growth of hospice has caused an increasing demand for qualified staff. Traditional recruiting tools such as classified ads, open houses, etc., are costing more and having fewer results. NHPCO and Choices Healthcare Solutions are offering an online job board/career center, Hospice Choices, to NHPCO members. In one year of operation, Hospice Choices has grown, by word of mouth, to more than 3,000 job hunters and 165 hospices. (NHPCO Newsline, 4/2005)
* An
article on alternative medical therapies in the Charleston Gazette refers patients to the
* The Agency for Healthcare Research and Quality (AHRQ) has provided an online report that shows state measures on 14 healthcare quality standards. Each state can be compared with the national average or with other states. AHRQ Administrator Dr. Carolyn Clancy says the states are not rated – “The picture is much too complex for that… Improvement is needed in every state.” See www.qualitytools.ahrq.gov/qualityreport/state for the online report. (National Healthcare Quality Report Website; PainAdvocacyCommunity, 5/2005)
* The American Geriatrics Society, The Atlantic Philanthropies, The John A. Hartford Foundation, and the AGS Foundation have awarded nearly $2.1 million for research to improve care of elder adults for Health in Aging. The awards went to 15 physician-researchers. (AScribe Newswire, 5/12)
PAIN & PALLIATIVE CARE NOTES
* Dr.
Scott M. Fishman, president of the American
*
* In an
editorial in The Boston Herald,
* In light of recent FDA actions on painkillers because of their side-effects, Consumer Reports on Health offers suggestions to patients who suffer from frequent pain. Use the lowest effective dose that will prevent flare-ups, begin with acetominophen, escalate to ibuprofen or naproxen if necessary, avoid NSAIDs if you have GI problems and consider Celebrex as a last resort. (Consumer Reports on Health, 6/2005)
* Vitas Healthcare Corporation’s senior director of public affairs Cherry Meier suggests a checklist of several items that may help determine whether a patient is a candidate for palliative care. Meier also says that regulatory changes could “go a long way toward improving partnerships between traditional hospice providers and nursing homes.” (Eli’s Long Term Care Report, 3/25)
HOSPICE & END-OF-LIFE NOTES
* Medscape has posted the transcript of an interview conducted by Dr. Perry G. Fine, NHPCO Vice-President for Medical Affairs, with former HHS Secretary Dr. Louis W. Sullivan. The interview is focused on hospice and palliative care. When asked what single piece of legislation he would promote to “create important and meaningful change in the area of end-of-life care,” Sullivan replied, “The most important challenge is to be sure that hospice is available to everyone.” The interview is online at http://www.medscape.com/viewarticle/504145?src=mp and requires a free one-time registration. (Medscape Nurses, 2005;56(1))
* The Harvard Health Letter distinguishes between living wills and advance directives, saying that though they’re easily confused, “advance directive” means both living wills and healthcare proxies. You need both documents, and they should “dovetail,” the article says. Your proxy is required to use “substituted judgment” if decisions must be made for you, meaning he or she should choose what you would have chosen for yourself if you were able. (Harvard Health Letter, 6/1)
* At its
annual shareholder meeting, Chemed Corp. said that it planned to expand Vitas
Healthcare Corp. into “every major
* For patients who resist DNR orders because they fear they’re choosing to die, some hospitals offer ANDs – Allow Natural Death orders. Though just another name for DNRs, some patients are more comfortable with the language that expresses that they are choosing to die naturally and comfortably. (NPR’s All Things Considered, 5/16)
*
* Former
Oregon Governor Barbara Roberts, who signed the state’s Death With Dignity Act
into law, campaigned for a similar law in
NURSING NOTE
* The
military and tsunami spending aid bill, signed into law last week, provides
50,000 extra visas for registered nurses and physical therapists. The one-time exception should cut the wait
for visas for nurses from