Hospice eNews 
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What the Media Said about End-of-Life Care This Week
Week of
June 27, 2005
…a
service of
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AAPM PRESENTS ETHICS
CHARTER ON PAIN TREATMENT
In the current issue of Pain Medicine, the Council of Ethics of
the
In Part I, “Foundations for the Ethical
Practice of Pain Medicine,” AAPM examines the physician’s professional
relationships and duty to the patient, ethics in private and academic practice,
referrals and conflicts of interest, relationships with pharmacists and
relationships to society at large. Meaningful change in improved pain
management, says the Ethics Charter, requires continuing education, effective
public policy and physicians’ advocacy “for the changes in regulations and laws
that compromise the ethical practice of Pain Medicine.”
Part II, “Ethical Opinions,” focuses on clinical concerns. Patients with diminished capacity for decision-making are discussed, along with systemic and psychosocial barriers to shared decision-making when treating pain. The Ethics Charter explores confidentiality as it pertains to the practice of pain management, pain and addiction, third parties and the patient-physician relationship. It further addresses research concerns such as the use of drugs for treatments that have not been specifically approved, informed consent and the use of placebos.
The
Ethics Charter includes a section on “Pain Medicine at the End of Life,” which
makes three main points:
* Pain relief: Physicians are ethically required to “manage pain according to currently available clinical science,” which may require consultation with pain specialists. Additionally, physicians should discuss the patient’s wishes for end-of-life pain treatment, assist them in developing advance directives and be “faithful in implementing these choices.”
* Patient Self-Determination and Comfortable Dying: “All reasonable means to relieve pain should be sought” when a patient is motivated by pain to end his or her life, but the inability of the physician to relieve pain “does not justify intentional hastening or causing the death” of the patient. However, physicians should not worry about hastening death by using opioids to control pain, since “medical ethics has long accepted pain control as an ethically defensible practice, even if it has unintended consequences in affecting the duration of a patient’s life.”
* Sedation for Intractable Pain: Palliative sedation, the induction and maintenance of “deep sleep to relieve pain that is refractory to standard palliative care,” is a “medically humane, ethical and legal alternative to the intentional hastening of death,” but “should be reserved as a intervention of last resort for the management of pain.” Palliative sedation “should be implemented and maintained by those with sufficient experience and expertise in end-of-life care, and in this procedure in particular.” Additionally, these patients should receive “psychological and/or spiritual interventions from a specialist trained to relieve end-of-life suffering.” (Pain Medicine, 2005;6(3):203-212)
ARTICLE REVIEWS SOME
CHALLENGES OF NEW HOSPICE COPS
The new hospice COPs may require a criminal background check on all employees before they are allowed to come to work, according to an article in Eli’s Home Care Week. Although 39 states already require some sort of criminal background check, the article says that new rules may be stricter than the current ones. In areas where checks can take weeks or months, hospices may face major staffing hurdles, the author says. The proposed COP may also require that hospices do background checks on contracted staff rather than allowing the contracted agency to perform them, but attorney Deborah Randall, with Arent Fox, says that is unclear.
Several experts found the proposed COP on hospice patients in skilled nursing facilities “sorely lacking in this area that is often a hot bed for compliance problems.” Arent Fox attorney Connie Raffa cites the fact that some intermediaries deny inpatient care for some hospice patients because the inpatient care benefit is classified as “short-term.” Raffa calls on CMS to do a better job of explaining criteria for inpatient care so patients don’t have to revoke hospice to get such care.
Although existing policy allows hospices to provide care out of satellite offices, a proposed COP would require CMS to approve a satellite office before it started providing care. Failure to obtain such approval would leave a hospice liable to exposure under the Final Claims Act, Randall says.
Hospices also may not contract for a specific level of care (such as continuous care), or for specific hours (such as evenings or weekends). The article says that this may cause problems for hospices that currently contract for continuous care with SNFs.
Another proposed change is the removal of the requirement for RN-provided patient care on a 24-hour basis in an inpatient facility. Additionally, hospices that use professional management companies would be required “to assume full responsibility for all of the hospice care provided to the resident.” (Eli’s Home Care Week, 6/20)
PAIN NOTES
* Dr. Scott Fishman’s editorial in Pain Matters was reprinted in full in the June issue of PainAdvocacyCommunity. Writing of the difficulties faced by pain specialists in today’s regulatory environment, Fishman says, “The maturing discipline of Pain Medicine must correct the problem of different doctors with different specialty training and perspectives, each just offering to the patient the narrow view of analgesia that we were taught in our primary residence programs… The field needs to be able to develop clinicians who can see the whole person and can give them the full breadth of care that they need.” The June issue of PainAdvocacyCommunity is online at http://www.partnersagainstpain.com/. (PainAdvocacyCommunity, 6/2005)
* Merck & Co. reports that an independent safety monitoring board has cleared Arcoxia, a successor to the withdrawn Vioxx, for further clinical study. The trials compare Arcoxia with diclofenac, an older painkiller, in 27,000 arthritis and rheumatoid patients. (The Record, 6/18)
* Dr. Scott M. Fishman, Chief of the Division of Pain Medicine at the University of California–Davis, has written the president’s message, “The Politics of Pain and Its Impact on Pain Medicine,” in the current issue of Pain Medicine. (Pain Medicine, 2005;6(3):199-200)
* “Natural marijuanalike chemicals in the brain have a link to pain
suppression,” says Daniele Piomelli,
professor of pharmacology at the
* Medical residents may
get insufficient training “to ensure competence and confidence in pain
management and the prescription of opioids.” An article in the Journal of Opioid Management reports on
the results of a survey of resident attitudes at
* Some of
the presentations from the 2005
annual meeting of the American
RESOURCE AND RESEARCH
NOTES
* See www.worldday.org for information about the new World Hospice & Palliative Care Day, scheduled for October 8, 2005. The event is a “new unified day of action to celebrate and support hospice and palliative care around the world.” (World Hospice & Palliative Care Day Website)
* The
* Information on the
airing of “Angels Among Us,” a documentary on
* “Supportive-Affective Group Experience for Persons with Life-Threatening Illness,” an article from the current Journal of Palliative Medicine, suggests that reduced death anxiety and an improved sense of spiritual well-being can result from participation in a support group. Another article in the same issue reports that nursing home patients are not receiving adequate pain management. These and other articles are available online at www.liebertpub.com/publication.aspx?pub_id=41.
* The National
Consensus Project for Quality Palliative Care (NCP) has created an advisory
committee to assist in disseminating its Clinical Practice Guidelines for
Quality Palliative Care. The
guidelines can be downloaded from www.nationalconsensusproject.org. (NCP
Press Release, 6/24)
PUBLIC POLICY NOTES
* The Senate has passed the Patient Navigator, Outreach and Chronic Disease Prevention Act of 2005, which now goes to the president for his signature. The bill provides $25 million in funding to increase access to early cancer screening and treatment. (Govtrack.us Website)
* Information on the National Pain Care Policy Act of 2005 and the Conquering Pain Act of 2005 is available at www.partnersagainstpain.com/painadvocacycommunity/05-11/Legislation.asp. (PainAdvocacyCommunity, 6/2005)
* A bill before the
* The AMA adopted a
policy opposing any legislation that presumes patients want life-sustaining
treatment unless they have indicated otherwise. Dr. Michael Williams, who was a co-sponsor of
the measure, said, “While the [Schiavo] circumstances
were heart-wrenching and compelling, they’re so rare that they’re not a good
basis to revise existing law.” (AP, 6/21; The
* The
OTHER NOTES
* The June issue of
“Military Officer,” the official magazine of the Military Officers Association
of
* Life is slowly returning
to normal at Woodside Hospice, where Terri Schiavo
died. Annie Santa Maria, director of
inpatient and residence services, has had trouble sleeping since all the
turmoil over Schiavo.
“I would watch volunteers feeding and bathing our patients day and
night, and they’re out there calling us murderers,”
* The current issue of MedSurg Nursing has two articles pertaining to
the Terri Schiavo case. One is a call to action on advance directives
from the
* Terry Hargrave, professor of counseling at