Hospice eNews

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

Week of June 6, 2005

…a service of Florida Hospices and Palliative Care

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COMPLICATED GRIEF DIFFERENT FROM GRIEF OR DEPRESSION

JAMA has published an article, “Treatment of Complicated Grief,” by Katherine Shear et al and AP issued an article about the study. The free article is available at jama.ama-assn.org/cgi/content/full/293/21/2601. Dr. Holly Prigerson, director of the Center for Psycho-Oncology and Palliative Care Research at Dana-Farber Cancer Institute, says that the term “complicated grief” has been in use about 10 years. “Unlike a lot of disorders following bereavement, including depression, it tends to persist for years and become a chronic distressed state - a sort of frame of mind,” according to Prigerson. Prigerson wants to have the disorder recognized in the next edition of the Diagnostic and Statistical Manual (DSM-V) of the American Psychiatric Association.

Dr. Richard Glass, professor of psychiatry at the University of Chicago, says that studies have shown that although some of the symptoms overlap, complicated grief isn’t the same thing as depression or post-traumatic stress. “The evidence so far indicates that there really is something totally different here,” Glass said. Key features of the methods of treatment of complicated grief, according to the new study reported in the current JAMA, include: 1) “a sense of disbelief regarding the death;” 2) “anger and bitterness over the death;” 3) intense longing for the deceased person, with recurring painful emotional pangs; and 4) “preoccupation with thoughts of the loved one.”

The study focused on different ways of treating complicated grief. The study included 83 women and 12 men, aged 18-85, in a university-based psychiatric research clinic and a satellite clinic in a low-income African-American community. All of the participants met the criteria for complicated grief. By random assignment, 46 received interpersonal psychotherapy (IPT) and 49 got complicated grief treatment (CGT). While CGT has much in common with IPT, CGT initially focused on personal life goals and addressed “traumalike symptoms” by asking patients to retell their experiences of the death. Patients were asked to imagine conversations with the loved one, playing both their own role and the deceased person’s role. While focusing on restoration, patients defined their personal life goals and were “encouraged to consider what they would like for themselves if their grief was not so intense.”

Outcomes were measured in one of two ways. One measure is by a score of 1 or 2 on Clinical Global Improvement, as rated by an independent evaluator. Another measure is by self-reported improvement of 20 points or more on the Inventory of Complicated Grief. While both treatments produced improvement, those getting CGT achieved a 51% response rate compared to 28% for those getting IPT. Those receiving CGT also had quicker response times. Patients who were taking antidepressants prior to the study had marginally better outcomes than those who were not.

The authors say that more work is needed, since only 51% responded to the treatment. They also note that the study was too small to validate several observations. Researchers noted that patients who had experienced violent loss had only a 13% response rate to IPT, and parents who had lost children showed a similar low response (17%) to CGT.

In a related JAMA article, Dr. Richard M. Glass poses, and answers, the question of whether or not grief is a disease. Glass provides a brief literature survey and reviews historical attitudes, noting that Engel thought grief fit the criteria for disease, while Freud did not. Glass notes that the report given in “Treatment of Complicated Grief” is “interesting and provocative,” but says that some broader issues need resolution. Better definitions are needed to distinguish “complicated grief” and “traumatic grief;” a consensus is needed about the amount of time the symptoms of complicated grief must be present for the diagnosis to be made and there is a question of whether complicated grief should be recognized as a separate mental disorder in DSM-V. Glass answers his question, of whether grief is a disease, by saying that it sometimes is a disease and that grief “warrants more research about effective ways to prevent and treat it.”

JAMA also has a grief page for patients. The information distinguishes between grief and abnormal grief, gives an overview of treatment options and provides links to several national mental health organizations. (AP, 6/1; JAMA, 2005;293:2601-2608, 2658-2660, 2686)

SURVEY EXAMINES QUALITY OF DYING AND DEATH IN ICU

Chest, the journal of the American College of Chest Physicians, featured an article entitled “Quality of Dying and Death in Two Medical ICUs.” The study “compared perceptions of the quality of dying and death in the ICU across nurses, resident physicians, attending physicians, and family members.” A survey assessed the “quality of the dying process” and examined differences in the perceptions of the different categories of respondents. Within 48 hours of a death, healthcare personnel were asked to complete a Quality of Dying and Death (QODD) instrument specially modified for use in the ICU. After one month, a family member was contacted by telephone and completed the survey orally.

“Family members and attending physicians gave the most favorable ratings of death, while nurses and residents provided less favorable ratings.” Significant differences were found between the groups on their perceptions about patient autonomy, being touched by loved ones, maintaining dignity and the “overall quality of death.” The authors conclude that more research is needed to explain these differences, as well as to determine whether the ICU QODD is useful for assessing and improving the quality of ICU end-of-life care. (Chest, 2005;127(5):1775)

PAIN NOTES

* Dr. Joshua P. Prager, pain specialist in Los Angeles, spoke at a recent psychopharmacology congress. Prager said that the World Health Organization should add a half-step and a new rung to its “analgesic ladder.” Prager’s half-step would be added between the mild and mild/moderate rungs and would include such new medications as Ultram, Neurontin, Cymbalta and others. His fourth rung would be at the top of the current ladder and would include patients with intractable or refractory pain. Treatments would include spinal cord stimulation, neuroablation and direct delivery of medications to spinal fluid. (Family Practice News, 2005;35(10):46)

* Many physicians are “fuming” and patients are “worried and confused” about the recent withdrawal of COX-2 inhibitors from the market. Dr. Elizabeth Tindall, president of the American College of Rheumatology, says, “The fallout of this will be that patients either go off their medications without supervision, won’t go on them even if indicated, or will be on them and have to listen to well-meaning family and friends telling them to get off. This decision has made caring for these patients even more difficult.” (Family Practice News, 2005;35(10):1)

* The results of a study of a meta-analysis of deep brain stimulation (DBS) for pain relief were recently presented to the American Association of Neurological Surgeons. Researchers do not yet understand the mechanism by which the fine electrically-stimulated electrode relieves pain. The study concluded that DBS “has an important role to play in the treatment of selected patients with chronic pain syndromes which have not responded to other forms of treatment.” (Science Letter, 5/31)

RESEARCH AND RESOURCE NOTES

* Circle of Life Hospice, in Springdale, Arkansas, will be part of a national clinical trial documenting the effects of massage therapy. Three patients will be enrolled each month for the duration of the study, which is being conducted by the University of Colorado Health Sciences Center under a grant from the National Institutes of Health. (Arkansas Democrat-Gazette, 6/2)

* The full text of “Wounds at the End of Life,” originally printed in Wounds, is available on the Medscape website. Medscape requires a one-time, free registration. More than one-third of the almost one million hospice patients in the US have wounds, about half of which are pressure sores. The authors suggest that knowing the characteristics of patients and wounds, as presented in the article, can provide a foundation for developing appropriate palliative treatment. See www.medscape.com/viewarticle/504322?src=mp. (Wounds, 2005;17(4):91-98)

* The list of state-selected delegates to the White House Conference on Aging (WHCOA) can be found on the WHCOA website, www.whcoa.gov/press/releases/releases.asp. The date of WHCOA has been changed from October to December 11-14, 2005. (WHCOA Website, 6/1)

* Findings presented at the recent American Society of Clinical Oncology say that 86% of more than 2300 breast cancer patients who were interviewed got care that adhered to more than 100 measures of quality. For some specific measures, the rate was higher, with more than 95% having the standard recommended number of lymph nodes examined and 92% of those who should have gotten tamoxifen actually getting it. However, the rate of adherence to the number of cycles of drug treatment and the amount of drug received in each cycle varied from 29-74%. The study also looked at patients with colorectal cancer. (The New York Times, 5/16)

* The Hospice Executive’s Salary and Benefits Survey, conducted by Hospice Letter, found that 58% of respondents were female. The average salary of males, however, was higher, at $67,708, than that of females, at $63,892. The average age of respondents was 50. Ninety-eight percent had at least “some college” education. Sixty-seven percent are registered nurses and another 13% are certified hospice and palliative nurses (CHPN). (Hospice Letter, 6/2005)

OTHER NOTES

* In a summary and analysis of the Papal Allocution on Pastoral Care on 2004, writer John Paul Slosar, PhD, director of ethics at Ascension Health in St. Louis, says there were three main themes: 1) “the intrinsic human dignity of every person;” 2) “the moral status of a refusal of life-sustaining treatment,” and 3) “the centrality of palliative care to the healing mission of the church.” Slosar says the allocution “highlights the necessity of training specialists in palliative care who can work within specialized interdisciplinary palliative care teams to carry out the central task of the church’s healing mission, namely, providing human and spiritual support to people living with life-threatening illness.” (Supportive Voice, Summer/2005)

* Representative Bill Thomas (R-California), chairman of the House Ways and Means Committee, called for a review of tax exemptions for non-profit hospitals. The Senate has opened its own inquiry, asking 10 of the largest non-profit hospitals detailed questions about operations. Thomas said that there’s not much difference between for-profits and non-profits and questioned what taxpayers get in return for “billions of dollars per year in tax subsidy.” (AP, 5/26)

* The Chicago Tribune reminded readers that a local man, Sidney Greenspan, had a story similar to that of Terri Schiavo. In 1984, Greenspan suffered a stroke that left him comatose. Four years later his wife went to court to have his feeding tube removed. The Chicago court refused, saying that since he was living with the feeding tube, he was not terminally ill. The Illinois Supreme Court reversed this decision. The writer reminds us that the lesson of both Schiavo and Greenspan is to make our own end-of-life decisions, communicate them clearly and formalize the decision with appropriate documents. (Chicago Tribune, 5/29)

* The Wisconsin Assembly Medicaid Reform Committee has proposed a requirement that new Medicaid enrollees file either a living will or a healthcare power of attorney with the state. It would require clients only to state their preferences without giving any direction as to what those preferences should be. If the bill is passed, Wisconsin would be the first state to require such documents. There is some disagreement over whether the proposal is even legal. (Milwaukee Journal-Sentinel, 6/2)

* The Richmond Times-Dispatch gave front-page coverage to the “poor man’s philanthropist,” Thomas Cannon. Cannon, who has colon cancer, is known for giving $1,000 checks to strangers for whom he has empathy. His main mission is philanthropy, but his secondary one is “to show people how to be unafraid of death.” He’s already taped his funeral service and is willing to “draw attention to his plight” because he wants to set a good example. (Richmond Times-Dispatch, 5/30)

* The VA is cutting back on funding for nursing home care for veterans. The VA is focusing, instead, on in-home care and the hope that Medicaid and the private sector can care for aging veterans in need of institutional nursing care. The Bush administration wants to cut the current 12,000 beds to 9,795, but the VA is already in violation of a 1999 federal law requiring a minimum of 13,391 beds. (Sarasota Herald-Tribune, 5/30)

* David Pruitt, who failed to die after taking his prescribed barbiturate overdose he requested under Oregon’s Death With Dignity law, said God told him not to end his own life. His brother, Steve, believes that proves the moral error of the law, but Pruitt’s wife, Linda disagrees. She says, “I really think I would not do it, but I do believe that each person has a right to make that choice.” Reporter Colin Fogarty says the debate in the Pruitt family is the same one going on in California over that state’s proposed physician-assisted suicide law. (NPR’s Morning Edition, 5/26)

* Palliative Care is a program initiated in May at the National Naval Medical Center. Program manager Jerry Waddell said, “The Center’s new Palliative Care program shows we are truly committed to Family-Centered Care. From birth to death, we are there with our beneficiaries every step of the way.” (US Department of Defense Information, 6/1)