Week of February 21, 2005
…a service of
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BETTER COMMUNICATION SKILLS MAY INCREASE HOSPICE USE
“Nurses’ Communication of Prognosis and Implications for Hospice Referral” is an online article at the Medscape website. Originally published in the American Journal of Critical Care, the article examines data from a prior study that sought to “identify common obstacles to nurses’ discussions of prognosis and referral to hospice care with terminally ill patients in the hospital setting.”
One hundred seventy-four nurses who worked full-time in community hospitals in areas where terminally ill patients routinely are cared for completed a self-administered survey. Questions were both closed- and open-ended. The open-ended questions asked for “common reasons that could account for lack of communication about prognoses and hospice referral, including why hospice care was sometimes not discussed at all with terminally ill patients and the patients’ family members, why some patients and family members were not told the terminal prognosis or why a delay occurred in telling patients and patients’ family members the terminal prognosis.”
Five major obstacles were identified that stood in the way of
communicating prognosis and making a referral to hospice.
* The patient or the family was unwilling to accept the prognosis or the referral.
* The death of the patient or a sudden change in patient status prevented communication.
* The nurses sensed that the physician was hesitant to discuss the matters.
* The nurses themselves were uncomfortable discussing prognosis or hospice.
* The nurses wanted to emphasize positive thoughts among the patients and families.
The authors write that “discussions between
acute care nurses and patients and patients' family members have a substantial
impact on patients' behavior,” and that “the manner and timeliness in which the
topics of prognosis and hospice care are broached may make all the difference
as to how a patient and his or her family members receive the news of the
terminal prognosis and/or how open they are to referral to hospice care.”
The authors strongly recommend that nurses develop skills for communicating with patients and families, “such as breaking bad news in a manner that is both realistic and sensitive. In addition, nurses should be knowledgeable about hospice care in order to educate patients and patients' family members about hospice philosophy so that the idea of hospice placement is not dismissed because of misinformation.” See www.medscape.com/viewarticle/498451?src=mp for the full article. Medscape requires a one-time, free registration. (Medscape Website)
NICU NURSES QUERIED ON EOL & BEREAVEMENT ISSUES
“Neonatal Staff and Advanced Practice Nurses Perceptions of Bereavement/End-of-Life Care of Families of Critically Ill and/or Dying Infants” examines nurses’ perceptions of their roles in bereavement/end-of-life care and the differences between the perceptions of RNs and advanced practice nurses (APNs). The article reviews the literature defining nurses’ responses to bereavement and end-of-life care issues in the neonatal nursery. One study revealed that sudden death and relapse of a patient ranked highest in terms of creating stress for nurses, although such an event was sixth in frequency of occurrence. Other studies indicated a desire for training in bereavement care and better support through hospital policies.
The article, originally published in American Journal of Critical Care, dealt with four major issues,
focusing on the differing perceptions of RNs and APNs.
* Comfort level of nurses with bereavement and end-of-life issues: When the years of experience in the NICU were factored in, RNs and APNs did not differ significantly on comfort level and most were “comfortable with many aspects of bereavement/end-of-life care.” Comfort level and years of experience in the NICU were significantly correlated. Fewer than half of both groups were comfortable discussing autopsy or organ donation.
* Nurses’ perceptions of their roles with families of infants who are critically ill or dying: Most respondents agreed about perceptions of their roles with families. Controlling for years of experience, there was no significant difference between RNs and APNs.
* Factors influencing nurses’ involvement with families of critically ill or dying infants: The two groups of nurses did not differ significantly on the total score. Factors rated as influential or very influential in familial involvement were caring for a dying infant, death of an infant and language and cultural differences. Most did not consider peer or nursing leader expectations as influential.
* Influences of education, professional role and level of NICU on end-of-life and bereavement issues: Fewer than half of those whose nursing curricula had covered such issues were satisfied with the coverage. Most who had continuing education on bereavement/end-of-life care rated it helpful or very helpful. Those working in level three NICUs were more comfortable than those working in level one or level two units.
The authors conclude that education and training may or may not affect
nurses’ perceptions of roles and involvement with families but can address
their comfort with bereavement/end-of-life issues, particularly topics such as
autopsy and organ donation. All levels
of nursing curricula need more end-of-life care content. Research on ways nurses can attend to
cultural issues surrounding grief is needed. The article is online at www.medscape.com/viewarticle/496385?src=mp. Medscape requires a one-time, free
registration. (Medscape Website)
PAIN, PAIN POLICY AND Rx ADVERTISING NOTES
* The
National Association of Attorneys General sent a letter, dated January 19, to
DEA Administrator Karen P. Tandy. The
letter, “signed by the attorneys general from 29 states and the
* An FDA
advisory panel recommended Friday that users of Celebrex, Bextra and Vioxx
should be allowed to keep using them in spite of increased risk of stroke and
heart attack. The panel, which found
that Vioxx posed the most risk and Celebrex the least, also recommended that
COX-2 inhibitors carry strong warnings and that long-term research be initiated
in order to better understand the drugs.
Though the FDA usually follows the recommendations of advisory groups,
it is not required to do so. (The
* Sales of prescription drugs for arthritis “plunged at the end of 2004” after last fall’s reports of potential cardiovascular problems from COX-2 inhibitors. In the same period, sales of non-prescription pain relievers more than doubled. An AP article says, “Doctors and other pain experts believe many patients are simply suffering in silence, confused about what pain medication is best for them.” (AP, 2/14)
* The New York Times columnist Jane E. Brody recently had both knees replaced, but suffered seven weeks of undertreated pain in the aftermath. Brody says her internist knew more about treating pain than her surgeon, because he has elderly patients with chronic pain that has to be managed. Brody says that patients should be proactive, insist on the help they need and educate themselves about the many ways to treat pain. (The New York Times, 2/15)
* An online interview with Dr. Judy Paice, director of the Cancer Pain Program Division of Hematology-Oncology at Northwestern University’s Feinberg School of Medicine, examines her views of finding optimal cancer pain relief. See www.partnersagainstpain.com/painadvocacycommunity/05-03/FirstPersAdv.asp for the interview. (PainAdvocacyCommunity, 2/2005)
* Jay Westbrook, clinical director for palliative care and bereavement service at Valley Presbyterian Hospital in West Van Nuys, California, says, “Doctors are much more likely these days to get into trouble for failing to manage someone’s pain than for writing an [inappropriate] prescription for OxyContin.” The article reviews the case of William Bergman, whose children sued his physician for undertreatment of his pain and won their case. It also notes the passage last fall of SB 1782, which requires the California District Attorneys Association to work jointly with law enforcement and medical groups to develop protocols for investigating alleged prescription violations by physicians. (Family Practice News, 2005;35(2):72)
* Stevens
Johnson Syndrome (SJS) is a rare but potentially fatal complication of pain and
other medications. SJS attacks the skin
and mucous membranes. Theoretically,
SJS can be caused by any drug, but sulfa drugs such as Bactrim, NSAIDs,
anticonvulsives and antigout drugs are most frequently implicated. The
* The
* While
the majority of drug advertising is aimed at physicians, direct-to-consumer advertising
rose from $800 million in 1996 to $2.7 billion in 2001. A Kaiser Family Foundation study estimates
that every dollar spent in direct-to-consumer advertising results in $4.20 in
sales. A National Medical Association
survey of African-American doctors found, however, an increase in diagnoses
because the “ads brought patients into the doctor’s office.” (
* Writing in the Annals of Family Medicine, medical ethicist Dr. Howard Brody says that doctors should “bar the door” to drug salesmen. US News & World Report cites Brody as saying that because drug reps must “put a product in the best light,” the information is untrustworthy and time spent on meetings about them is wasted. Still, he says, clinical decisions are based on them. More frequent meetings lead to increased prescription of the products. Brody calls on doctors to read journals, use online resources and stock up on cheap generics to hand out to patients in need. (US News & World Report, 2/14)
* Scientists
are looking for new treatments in chemicals from such diverse substances as
marijuana, nicotine and snail and fish toxins.
Other efforts target variations of existing treatments. Dr. Russell Portnoy, chairman of pain
management and palliative care at
END-OF-LIFE NOTES
* Over
the objections of her daughter,
* A
Texas appellate court will decide whether to reverse the decision of Judge
William C. McCulloch that Texas Children’s Hospital could decide the fate of
Sun, a five-month-old baby with a terminal illness. (See HNN,
2/15) If McCulloch’s ruling stands,
medical history would be made, since no judge has ever allowed discontinuation
of life support of a child when the parents’ objected, though hospital
decisions have been upheld in court after a child’s death. (The
* The attorney for Bob and Mary Schindler, Terri Schiavo’s parents, filed a motion to delay removal of her feeding tube so that “new medical technology could better assess” Schiavo’s brain activity. A study in the journal Neurology reported that some severely brain-damaged patients have a “pattern of brain activity similar to that of healthy people.” A bill has been filed in the Florida Senate that would prohibit the withdrawal of nutrition and hydration unless specifically noted in a living will. If passed, the law would apply to the Schiavo case. (AP, 2/17, 2/14)
OTHER NOTES
* A report published in NEJM says that a broken heart can kill you. Though none of them had a heart attack, nineteen patients developed serious heart problems after an emotional upset, five of them serious enough to have died without treatment. The patients’ levels of catecholamines – stress hormones, of which adrenalin is one – were two-to-three times as high as usually seen during severe heart attacks and up to 34 times normal. Researchers don’t know if the high hormone levels were the cause of the problem or the result of it. (Time Magazine, 2/21)
* A review by national investment bankers Houlihan Lokey Howard & Zukin found 2004 to be an “exceptional year” for the publicly-held companies in the home care industry. The average stock price of the 11 companies rose 17.4%. On the down side, hospice stock prices slid 53%, partly caused by the Justice Department’s decision to investigate Odyssey Inc.’s admission and billing practices. In spite of that, hospice revenues grew 13% this year. (Home Health Line, 2/11)
* The American Medical Association, the National Medical Association and the National Hispanic Medical Association announced a new alliance, the Commission to End Health Care Disparities. Randall Maxey, co-chairman of the commission, says, “We’re targeting physicians first.” The group hopes to heighten physicians’ awareness of the issues and lessen the “bad outcomes in healthcare for ethnic minorities because there’s still racism.” Maxey says, “We want to equate cultural competence to clinical competence.” (Modern Healthcare, 2/14)
* A bill
before the