Hospice eNews

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

Week of August 15, 2005

…a service of Florida Hospices and Palliative Care

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AARP MAGAZINE ARTICLE CLAIMS MANY ARE PAIN’S PRISONERS

An AARP Magazine article, “Prisoners of Pain,” notes that “75 million Americans suffer from chronic pain” and many do not receive the pain relief that they need. “Much of this suffering is preventable,” says the article, but physicians have not received adequate training in pain management and, further, some live with fear of the DEA. Consumers, too, are worried about issues related to addiction.

The article includes statements from several pain specialists, including Scott Fishman, chief of the division of pain medicine at the University of California, Davis, and president of the American Academy of Pain Medicine. While everyone who is in pain cannot be cured, Fishman says, “We can make almost everyone feel better.” James Campbell, Johns Hopkins University, sees that this fear of the DEA is hurting citizens and says, “‘Five years ago we were actually doing a better job at handling pain patients. Now we’ve seen a backslide, and patients are definitely the victims. They’re suffering.’” Russell Portenoy tells of his first day as a licensed physician and shares how his fear kept him from providing adequate treatment to a patient in pain. Portenoy, along with others, has encouraged physicians to “become bolder in treating patients’ suffering.”

The article relates the progress made in encouraging appropriate use of opioids, including taking pain more seriously, encouraging better practices and seeking action against physicians who fail to manage pain well. Still, there is no assurance that any American will receive good pain management, and according to UC Davis bioethicist Ben Rich, “The odds of your getting good pain management are, at best, 50-50.” Provider and patient fear of addiction are a key factor. Physician Diane Meier says that she confronts this fear even in her own family. And another healthcare provider tells the story of a cancer patient whose primary doctor told her, “Don’t take your pain medicine. Let the pain kill the cancer.”

The article includes the story of Arizona physician Jeri Hassman, whose office was “stormed” by federal agents. The DEA declined to make comment for this article, but “physician groups and patient advocates point to a growing list of respected pain doctors who have been prosecuted by the DEA and by state medical boards.” The DEA says the agency “arrests fewer than 100 doctors a year on drug-diversion charges.”

The article provides several tips to consumers. Readers are advised to read dosage directions carefully and to follow them exactly. Readers are urged not to mix medications and to “do the math” and watch the amount of medications that they take. (AARP Magazine, September, October, 2005)

FEEDING THE GRIEVING HAS “FUNDAMENTAL AIM”

Vertamae Grosvenor, cultural correspondent for NPR, always wondered why people ate so much after funerals. “Even people on diets ate plate after plate,” Grosvenor said. “My theory was, we ate so much because that’s how we knew we were alive.” But Dr. Holly Prigerson, a bereavement specialist, says that in addition to reflecting ethnicity and contemporary funeral practices, funeral meals have a fundamental aim. She cites C. S. Lewis’ quote, “No one ever told me that grief felt so like fear,” and adds, “You can’t be noshing when something’s chasing you.”

Prigerson says, “Grief triggers the fight-or-flight mechanism. Your body’s in a state of alarm. …. When grieving people say they don’t feel like eating, that’s because the body is prioritizing for survival.” The postfuneral meals offer emotional support to the grief-stricken, but people also take food “out of a basic human sense that people who have survived the death of someone they love are going to need nourishment. They’ve been depleted by caregiving and bereavement. Grieving people must eat.” So family and friends bring food to the home and sometimes to the funeral home.

But in some areas, the state interferes. A New York state law prohibits the “preparation, sale, service or distribution of food or beverages in any part of a funeral establishment to or by friends, relatives, mourners, family, visitors or next of kin of any deceased person.” In Wisconsin, on the other hand, the owner of Becker Ritter Funeral Homes can offer a catered meal that “reflects the person being remembered.” Joseph Becker says they’ve had a replica of an English high tea, a German oompah band, and, for a Norwegian woman, a dinner in all the colors of the Norwegian flag. Becker says he offers the service because, with the growth in cremations, there’s no immediate trip to the cemetery. “I started looking down the road at the future. I wanted to offer something of value to the people we serve,” he says.

The author writes, “The funeral meal’s most influential designer is religion, but there is room for flexibility.” One rabbi noted the presence of more health-conscious food, such as vegetable trays with dips and less fried food than in the past. Both Hindus and Jews use specific foods to mark different stages of the mourning process. For Muslims, the funeral meal “is a form of charity for the friends and relatives who’ve come to the funeral. The blessing from that charity goes to the deceased,” according to Imam Mateen Siddiqui, of the Supreme Islamic Council of America in Fenton, Michigan.

Vertamae Grosvenor says that funeral meals in the South Carolina Low Country were “when you showed off. Maybe you didn’t bring your best to a party, but to a repast you did.” You showed off your rice dishes because the Low Country is rice country, and “We had pans and pans of rice fixed every kind of way… People judged your worth by how well you made rice. If your rice wasn’t proper, my God. Gummy rice wasn’t only unfit for a living person, it was unacceptable for a dead man.” (The New York Times, 8/10)

ALASKANS NEED TO SLOW RISE OF HEALTHCARE COSTS

The civic group Commonwealth North has issued a report, “Alaska Primary Health Care: Opportunities and Changes.” State and medical speakers who discussed the report at a recent Alaska State Chamber event said, “Alaskans must make major changes to slow rising costs in many small ways.”

Speakers made the point that “high expenses and poor health stem from more resources going to emergency and end-of-life care than prevention.” They also suggested that patient payments to healthcare systems should be higher “as incentive to be well,” and that patients should be educated “to better manage chronic conditions and detect illnesses earlier.”

The author says that end-of-life issues are just as crucial as wellness but harder to face. Keynote speaker Maura Donahue, chairwoman of the US Chamber of Commerce, said, “One Terri Schiavo incident on one of our group plans could be devastating. We have to make sure advance directives are in place.” Jim Jordan, head of the Alaska State Medical Association, uses the example of a drug that helps skin cancer patients live several months longer, but which costs $48,000 compared to $170 for a less effective generic. “We in the US have not had the intestinal fortitude to face that,” he said.

Heyman says that health care costs 40% more in Anchorage than in Seattle and costs even more in other areas of the state. The US has obesity rates twice those of Western Europe, and Alaska has the worst rate in the country. At two Alaskan institutions, Providence Alaska Medical Center and Alaska Regional Hospital, bad debt tripled between 2000 and 2004, rising to nearly $90 million.

The article cites several small solutions that are becoming more widespread. Robot-assisted surgery, relatively new to the state, is cheaper because it requires less operating room labor and patients leave the hospital sooner because of fewer post-surgery complications. After ear surgery, children living in remote areas are checked by a special camera rather than flying with a parent to Anchorage. The state, following Utah’s example, is working to allow children up to the age of 26 to be covered on their parents’ policies. One item on the wish list is a database for electronic medical records so that patient information can be kept securely. Commonwealth North is collecting $10,000 donations to spur development of creative solutions for the state’s rising costs. (Anchorage Daily News, 8/10)

PAIN NOTES

* A new study from M. D. Anderson Cancer Center compared oral analgesics, given according to a specified protocol to lung and prostate cancer patients, to analgesics given at the physician’s discretion. The proportion of patients having no pain or only mild pain at the end of the study was significantly higher for those treated according to the protocols. The study was originally published in the Annals of Oncology. (Women’s Health Weekly, 8/18)

* “Improving Cancer Pain Relief in the World” has been published by the Pain & Policy Studies Group of the University of Wisconsin Comprehensive Cancer Center. The report is online at www.medsch.wisc.edu/painpolicy/publicat/04report/04report.pdf. (PPSG News Alert, 8/9)

RESEARCH AND RESOURCE NOTES

* A study of Dutch physicians obtained “information about the characteristics of requests for euthanasia and physician-assisted suicide and to distinguish among different types of situations that can arise between the request and the physician’s decision.” A related article assesses physician compliance with rules for euthanasia and assisted suicide. (Archives of Internal Medicine, 2005:165:1698-1704)

* The current issue of Pain Medicine has a number of articles focused on pain and pain management. The articles include “Puzzling Pain Conditions: How Philosophy Can Help Us Understand Them,” “Treatment of Intractable Constipation with Orlistat,” “The Clinical Art of Pain Medicine: Balancing Evidence, Experience, Ethics and Policy” and “Evidence-Based Oral Transmucosal Fentanyl Citrate Dosing Guidelines.” The online issue, which requires a paid subscription but has free abstracts, is at www.blackwell-synergy.com/toc/pme/6/4. (Pain Medicine, 7/2005)

* The John H. Stroger, Jr. Hospital in Cook County, Illinois, is the recipient of a $175,000 Aetna grant to develop a palliative and end-of-life care program for trauma units. The intent is for the model program to be shared with other urban trauma units across the nation. (Business Wire, 8/11)

* The Hospice and Palliative Care Nurses Foundation (HPNF) and Sigma Theta Tau International Honor Society of Nursing Research Grant in End-of-Life Care for this year will be used to “examine various influences that impact older adults’ ability to comprehend healthcare communications.” Award winner Mary Judy Campbell, MSN, EdS, RN, will “explore how understanding and application of information affects health outcomes as well as attitudes on completing advanced directives.” (HPNF Press Release, 8/11)

* Reviewer Stuart M. Lichtman, MD, of Memorial Sloan-Kettering Cancer Center, cites a number of omissions that would have strengthened Comprehensive Geriatric Oncology had they been included but says that the “shortcomings … are more than compensated for by the text’s scope and detailed insights into cancer and aging.” (JAMA, 2005;294:745)

* “Prognosis and Decision Making in Severe Stroke,” in the current JAMA, says, “An increasing number of deaths following severe stroke are due to terminal extubations. Variation in withdrawal of care practices suggests the possibility of unnecessary prolongation of suffering or of unwanted deaths.” (JAMA, 2005;294:725-733)

OTHER NOTES

* Senators questioned Supreme Court nominee John G. Roberts Jr. on his views about the actions of Congress to overturn court orders withdrawing Terri Schiavo’s feeding tube. When asked about Congressional intervention in an end-of-life case, Roberts replied, “I am concerned with judicial independence. Congress can prescribe standards, but when Congress starts to act like a court and prescribe particular remedies in particular cases, Congress has overstepped its bounds.” (The New York Times, 8/10)

* An article in the St. Louis Dispatch highlights how caregivers’ own health often suffers during the process of caregiving. Judy Auclair cared for her husband at home for four years as he died of brain cancer. But “her determination to make the last years of his life wonderful took a toll on her own,” as her weight ballooned by 30 pounds and she suffered from low back pain and depression. (St. Louis Dispatch, 8/8)

* Lance Tibbles, Professor of Law at the Capital University Law School near Columbus, Ohio, says that biomedical technologies create “dilemmas and paradoxes,” fragmenting natural processes and reassembling them in new configurations. Tibbles examines how this process may explain the expressed discomfort of some people on Michael Schiavo’s involvement with another women while still being responsible for the care of his wife, Terri. (National Law Journal, 8/1)

* Even though non-profit organizations are not bound by the Sarbanes-Oxley Act of 2002, the ratings agency Fitch supports “the creation of a formal regulation of not-for-profit healthcare providers that mirrors” it. The Fitch report, “Sarbanes-Oxley and Not-For-Profit Hospitals: Increased Transparency and Improved Accountability,” describes the nine sections of Sarbanes-Oxley that are pertinent to healthcare providers. (Modern Healthcare’s Daily Dose, 8/9)

* The American Association of Colleges of Nursing says that more than 32,000 qualified applicants were not admitted to the nation’s 1,500 nursing schools because of the faculty shortage. Hospitals, who desperately need more nurses, are dedicating resources to colleges and universities in an effort to ease the shortage, mostly by supplying clinical staff for student supervision. (Akron Beacon Journal, 8/8)