Hospice eNews

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

Week of July 4, 2005

…a service of Florida Hospices and Palliative Care

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CHEST STRESSES EOL COMMUNICATIONS WITH COPD PATIENTS

“Barriers and Facilitators to End-of-Life Care Communication for Patients With COPD,” an article in the June issue of Chest, reports on a study that identifies those barriers and facilitators of physician-patient communication. Focus groups of COPD patients determined 15 barriers and 11 facilitators to good communication for patients nearing the end of life. Then, 115 patients and their physicians were surveyed to determine the common barriers and facilitators and their association with communication about end-of-life care.

Thirty-two percent of patients reported having an end-of-life conversation with their physicians about the kind of care they would want if they were unable to communicate themselves. But nearly 75% said that their doctor “definitely or probably knows” what they would want done. More than 50% of patients endorsed two barriers that say, “I’d rather concentrate on staying alive,” and “I’m not sure which doctor will be taking care of me.” Two barriers, with a significant association with lack of communication, say, “I don’t know what kind of care I want,” and “I’m not sure which doctor will be taking care of me.”

The more barriers patients endorsed, the less likely they were to have had an end-of-life discussion with their physicians. The converse was also true – endorsing more facilitators indicated that a patient had a more likely possibility to have discussed end-of-life issues with a physician.

The four most common facilitators endorsed by patients were those that say, “I have had family or friends who have died” (88%), “I trust my doctor” (87%), “My doctor is very good at taking care of lung/respiratory disease” (83%) and “My doctor cares about me as a person” (83%). The facilitator least frequently endorsed says, “My doctor often asks me about end-of-life care,” which was chosen by fewer than 10% of the patients. Two facilitators chosen by those who had already had end-of-life discussions say, “My physician is good at talking about end-of-life issues” and “Others have talked to me about end-of-life care.”

The only barrier endorsed by more than half of the physicians says, “There is too little time during our appointments to discuss everything we should.” This barrier was chosen by 64% of respondents. The second and third barriers most frequently chosen said, “I worry that discussing end-of-life care will take away his/her hope” (23%), and “The patient is not ready to talk about the kind of care she/he wants if she/he gets sick” (21%).

Three of the physician facilitators were endorsed by more than 70% of the physician respondents. “The patient and I have a good relationship” was chosen by 85%, “I have cared for many patients with lung disease” by 80% and “The patient has been very sick in the past” by 71%.

Other factors affected which barriers and facilitators were selected. Men were more likely to endorse that “Doctors look down on smokers” and nonwhites were more apt to choose “I feel that talking about death can bring death closer.” Female physicians were more apt than males to select “I work in a system that expects me to have end-of-life discussions with patients.” Nonwhite physicians chose four barriers more frequently. These barriers say, “This patient doesn’t know what kind of care he wants if he gets sick,” “This patient is not ready to talk about what kind of care he wants if he gets sick,” “This patient’s ideas about the kind of care he wants change over time” and “I worry that discussing end-of-life care will take away his hope.”

The researchers suggest that one way to increase patient-physician communication about end-of-life care is to include non-physician clinicians in these discussions, noting that study patients who had discussed end-of-life care with other clinicians were more likely to have done so with their physicians. They conclude that the identified barriers and facilitators “are targets for interventions to improve end-of-life care, but such interventions will likely need to address the specific barriers relevant to individual patient-physician pairs.” (Chest, 2005;127(6),2188)

A companion article, “Recognition and Communication: Essential Elements To Improving End-of-Life Care,” says that palliative care in COPD is “not well researched.” The authors suggest that one reason is the nature of the disease’s “slow progression punctuated by acute exacerbations” which “obfuscate[s] the point at which the illness should be considered potentially terminal.” The study article, say the authors, “supplies us with no easy answers” to the problems of developing better patient-physician communication. “However,” they note, “It is another step forward toward achieving the goal of improved end-of-life care communication.” (Chest, 2005;127(6),1886)

PAIN NOTES

* In an op-ed article in The Boston Globe, Massachusetts state Senator Steven A. Tolman (D) again called for banning OxyContin, saying that the burdens outweigh the benefits. A related article in The Washington Post says that teenagers are the fastest growing group of prescription drug abusers and they arrange “pharming parties” and swap drugs obtained at home or on the street. (The Boston Globe, 6/30; The Washington Post, 7/8)

* Patients who choose to avoid pain relievers because of possible heart complications may feel a new and different kind of pain – one in the wallet. Though many alternative therapies exist, insurance companies may pay only for limited coverage, such as for two months of physical therapy. For other therapies, such as acupuncture, insurers may not pay at all. Some insurance companies that refuse to pay for the treatments themselves have negotiated discounts for members with chiropractors or acupuncturists. (The Boston Globe, 7/5)

* Purdue Pharma, maker of OxyContin, is laying off 38% of its work force (825 employees) after it lost a patent case that allows the sale of generic OxyContin. Ivax Pharmaceuticals, Inc. will be the authorized US distributor for generic OxyContin. Oxycodone HCl controlled release tablets C-II are the generic equivalent of OxyContin and will be available in 10, 20, 40 and 80 milligram doses. (; AP, 7/1; Drug Week, 7/8)

END-OF-LIFE NOTES

* Tributes, an event planning company in Northern Virginia, plans for events to be held after death. “Think wedding planners without the bride,” says an article in USA Today. According to the article, this company does everything for you but the embalming and bringing you back from the dead. Palm Mortuary in Las Vegas offers “life celebrations” sets, such as scuffed boots on bales of hay, golf displays or the deceased person’s motorcycle. Preplanned, personalized funerals are a rising trend, and the website of the National Funeral Directors Association contains a section called “Types of Tributes.” (USA Today 7/6)

* An innovative Medicaid program in Florida will provide family counseling and respite services to critically ill children without requiring that they be in the last six months of life. HHS Secretary Mike Leavitt called the program “the right thing to do for these most vulnerable children and their families.” (PR Newswire, 6/30; States News Service, 6/30)

* Montefiore Medical Center in the Bronx is pioneering a team of doctors and ethicists to mediate medical conflicts at the end of life. The team is attracting national attention in the wake of the Schiavo case and is “innovative in giving its bioethicists a central role in mediating end-of-life issues among doctors, nurses, patients and family members.” (The New York Times, 7/4)

* Leana S. Wen, national president of the American Medical Student Association, said, “Too often, patients die alone in pain and attached to machines without regard for their wishes. Future physicians must be knowledgeable on end-of-life issues and be able to provide the best possible care for their patients and their families who are facing death. AMSA urges all medical schools and residency programs to offer electives to educate medical students and residents in issues of death and dying.” (ProfNet Wire Website, 7/8)

RESEARCH AND RESOURCE NOTES

* An Idaho group, A Better Way Coalition, has put the new streamlined Idaho Medical Consent and Natural Death Act document on its website, along with a new advance directive wallet card and other end-of-life information. The group has also launhed a new website at www.abetterwaycoalition.org. (The Idaho Statesman, 7/4’ A Better Way Coalition website)

* Poor people are more likely to die in pain than rich people, according to a University of Michigan study to be published in the August issue of the Journal of Palliative Medicine. Men and women aged 70 or older and worth more than $70,000 were 30% less likely to have frequent pain in the last year of their lives than those less well off. They also had less shortness of breath and depression, as well as fewer symptoms overall. (University of Michigan News Service, 7/5)

* A recent national survey of physicians and the general public found that “a clear majority” approves of medical marijuana. Seventy-three percent of physicians and 78% of the general public approved of the use of marijuana to reduce symptoms of AIDS, cancer and glaucoma. Seventy-five percent of physicians and 80% of the public did not believe the government should be able to prosecute patients who grow physician-prescribed marijuana for chronic fatigue and pain. Similar percentages approved state laws allowing medical marijuana use. (Pharma Law Weekly, 7/12)

* Independent Sector, a coalition of foundations, charities and corporate-giving programs, has released a checklist for tax-exempt organizations to use to ensure “transparent and ethical governance.” The list comes after a June report to Congress that recommended more than 120 actions to be taken by Congress, the IRS and non-profit organizations. “Elements of the nine-point checklist include: adopt a statement of values and code of ethics; hire an independent auditor or accountant; publish financial and governance statements online; and ensure directors understand their financial responsibilities.” (Modern Healthcare’s Daily Dose, 7/7)

OTHER NOTES

* A Charlotte Observer article briefly introduced palliative care to readers. Dr. John Barkley is director of Palliative Care Consultants, which has worked with over 1000 patients in its two-year existence. Barkley says, “Patients and families have been wanting this for a long time.” (Charlotte Observer, 7/4)

* “Improving the ICU” is the first of a two-part treatise which discusses “existing problems in ICU care and the methods for defining and measuring ICU performance.” Among the problems cited are non-adherence to published standards of care, poor communication and teamwork, poor problem solving and major deficiencies regarding palliative and end-of-life care. (Chest, 2005;127(6),1886)

* “Treatment Preferences for Resuscitation and Critical Care Among Homeless Persons” examines the decision-making preferences of homeless people and guides surrogates making medical decisions for them. The study concludes, “Homeless persons are more likely to prefer resuscitation than physicians and patients with COPD.” (Chest, 2005;127(6),1886)