The Hospice e-News
What the Media Said about End-of-Life Care This Week
Week of
…a service of
Wuesthoff Brevard Hospice & Palliative Care is holding its second annual Hospice
African-American Community Breakfast on
NEWS from
HOSPICE of Lake & Sumter
Contact:
Public Information Manager
Happy Valentines Day from Space
TAVARES
-- The large field in front of Hospice of Lake and
But Hospice staffers were surprised
recently when one of them happened to visit a web site of Earth photos taken by
satellites. They discovered that the
heart image is clearly visible from many miles up! It appears on a photo taken by the U.S.
Geological Survey and presented on the Terraserver
web site.
Go to terraserver-usa
and use the search device on the home page to locate
Happy Valentines Day from Hospice!
OFFERING PALLIATIVE
Twenty-five percent of deaths in the
Patient transfers from one setting to
another “are fraught with risks of medical errors and increased patient and
family distress,” and require that “new clinicians assume responsibility at a
critical time for patient and family.”
Hospital physicians who are transferring patients should make sure that:
* Additional acute care will not benefit the patient.
* Pain and other discomforts during transfer can be minimized with proper treatment.
* The patient’s life expectancy is long enough for benefits from the new setting to be realized.
Palliative care patients who leave the
hospital but are not able to go home usually have the options of inpatient
hospice, residential care with hospice or nursing home care with or without
hospice. The authors suggest questions
that the physician can ask to determine which level of care is most
appropriate:
* Dedicated hospice unit: Is the service available in the community? Can the patient be admitted for short stays for intensive management of symptoms? For longer stays with less intensive palliative care?
* Nursing home with hospice: Does the nursing home contract with a hospice? Will the nursing home accept a Medicare patient into hospice and forgo the benefit for skilled nursing? Will the accepting physician use the palliative care plan?
` * Nursing home without hospice: Does the nursing home have access to pain and/or palliative care consults? Does it have private rooms? Is there a chaplain? Are there policies and procedures for assessing and managing symptoms? Is the staff trained in end-of-life care? Do the nursing home leaders endorse palliative care? How does staff respond to a crisis in symptoms if the patient is not a hospice patient? Will the accepting physician use the palliative care plan?
* Residential care with hospice: Does the facility contract with a hospice? Are terminally ill patients allowed to remain in the facility? Will the accepting physician use the palliative care plan?
One issue of financial importance is that it may be difficult to discharge a hospice patient directly from the hospital to a nursing home. If the only insurance that a patient has is Medicare, the patient must elect either the Medicare hospice benefit or the skilled nursing benefit and is not eligible for both. The authors say, “The skilled nursing benefit is economically advantageous to both patient and nursing home due to more complete coverage,” but additional coverage is available if the primary or secondary insurer is Medicaid.
Patients, families and healthcare professionals express concerns about dying in nursing homes. A recent national study found bereaved families less satisfied with nursing home care than those in all other settings. The authors cite “staff turnover, limited training, insufficient staffing, regulatory pressures and reimbursement rules” as “major barriers to high quality care.”
One thing hospital palliative care teams
can do to ease the problems of transfer to a new facility is to write discharge
orders that anticipate symptoms that escalate.
“On-call” orders can be used for medication during transfer and sliding
scale orders can cover mild, moderate or severe symptoms. Treatment protocols, which direct management
of acute complications, can be included with the hope of avoiding readmission
to the hospital.
Documentation transferred with the patient
should be clear about the goals of care and treatment decisions. Copies of living wills, advance directives,
healthcare powers of attorney and information about life-sustaining treatment
decisions should be included.
The authors suggest several interventions
to improve palliative care outside of hospitals. These include:
* Goal-centered advance care planning and careful documentation of the same;
* Physician Orders for Life-Sustaining Treatment (POLST) form;
* Discussion of interventions by nurses with patients and families;
* Social-workers facilitating communication;
* Palliative care training for all staff;
* Quality improvement interventions to improve management of pain and increase hospice enrollment, and discussions of advance care planning;
* Routine hospice screening, and
* Specialized units and staffing.
In conclusion, the authors recommend that
hospital-based physicians “learn to identify the most promising post-acute care
settings in their community. When
benefits of transfer outweigh risks, they should maximize quality and
continuity of care by communicating treatment goals, life-sustaining treatment
orders, and anticipatory orders for symptom management.”
Additionally, they say, “Physicians and nurses in long-term care will serve increasing numbers of dying patients. Training in generalist disciplines, geriatrics, and palliative care should prepare these health care professionals to treat dying patients in long-term care settings. Early research on innovative approaches to advance care planning, clinician training, and new ways to deliver hospice and palliative care can serve as a guide for larger and more rigorous studies and for dissemination of improved palliative care services.”
The JAMA issue also has a patient page which explains what hospice is, the goals of hospice care, the services provided by hospice and hospice’s team approach. (JAMA, 2006;295;681-686, 712)
ARTICLE EXAMINES PALLIATIVE CARE ’S PAST AND
FUTURE
“The Past and Future of Palliative Care,”
by Dr. Kathleen M. Foley, attending neurologist in the Pain and Palliative
Care Service at Memorial Sloan-Kettering Cancer Center, is another in the series of articles in the recent Hastings Report. Foley says
that a national dialogue on advancing palliative care and expanding hospice
services in the
Foley briefly recounts the hospice movement in the United States, calling it a “grassroots movement to improve the quality of dying for patients at home.” The palliative care movement, on the other hand, has been fostered by healthcare professionals and aims “to improve the care of the seriously ill and dying in the hospitals and nursing homes where more than 55 percent of Americans die.” The two movements have common themes – “to improve the quality of life for patients with serious, chronic illness, and for their families as well.”
Foley cites the “confluence” of major events in the development of hospice. “An enormous and defined need, philanthropic leadership, professional leadership, and public awareness” are the catalysts that led various end-of-life care professionals and institutions to “build the field of palliative care.” But early on, the expansion of palliative care was viewed by some as a threat to hospice. Another “subtle but perhaps more serious concern was that the developing field of specialist palliative care and palliative medicine might further medicalize care of the dying and be antagonistic to the very values and traditions for which hospice had evolved to counteract the medicalization of death.”
Foley says that the best description of the future of palliative care can be found in the National Consensus Project’s Clinician Practice Guidelines for Quality Palliative Care, available for download from www.nationalconsensusproject.org/Guidelines_Download.asp. The document, which “represents a major collaborative effort between palliative care and hospice professionals to define the field of palliative care in a way that is responsive to the needs of its various stakeholders,” sees hospice as one component of palliative care.
The growing need for, and implementation of, palliative care units within hospitals is challenging the ability of hospice to reach patients. Shorter lengths of stay and “brink of death” admissions give hospice little time to “prepare patients and families for death.” Improving technology and “expensive supportive therapies” are challenges to the financial structure of hospices, now dependent on a per diem rate.
In spite of a growing number of hospice and palliative care certified professionals – more than 2,000 physicians and 10,000 nurses and nursing assistants – studies show that demands for palliative care professionals are increasing. There is growing interest in American hospitals in palliative care units, which can improve the financial standing of hospitals while also improving the quality of care received by patients and families. In response, half of all hospices have developed close alliances with academic hospital programs, hoping to bridge the gap in services and to support palliative care consultations for hospitalized patients. Bridging that gap is “an important component in developing a model of continuity of care for patients with serious life-threatening illness,” Foley writes.
Foley sees the future of palliative care as being determined “in part by its integration into mainstream health care.” Twenty percent of American hospitals now have palliative care units or consultation teams. Another encouraging example of progress is NIH’s State of the Science meetings that have identified research “with a rich potential to advance the field,” and the accompanying recommendations that the research be funded.
Prior efforts to improve hospice and palliative care “have been slow and incremental and have engaged a broad range of stakeholders,” Foley writes. But “Americans are increasingly aware of the importance and opportunities for care that emphasizes their quality of living and reduces needless suffering. Such information is transforming their perspectives on choices and options for care and will lead to the full integration of hospice and palliative care into the health care system. The confluence of a grassroots consumer activism for choice, care, and quality with health care professional who are focused on reclaiming their professionalism offers an optimistic future to improve care for this vulnerable population.” (Improving End of Life Care: Why Has It Been So Difficult?; National Consensus Project Website)
Editor’s note: This is one of a series of articles from a recent The Hastings Report, “Improving End of Life Care: Why Has It Been So Difficult?” We will continue the series as space permits.
LAST CALL FOR RESPONSES ON NQF PALLIATIVE CARE
REPORT
A draft
copy of “A National Framework for Palliative and Hospice Care Quality
Measurement and Reporting” has been issued by the National Quality Forum
(NQF). With funding from the Robert Wood
Johnson Foundation, the NQF began the project in 2005 to “1) endorse a national
consensus framework for evaluating the quality of palliative and hospice care
across all health settings and professions; 2) achieve consensus on a set of
preferred practices for palliative and hospice care based on the framework; and
3) identify areas for research in palliative and hospice care quality.”
Public comments have been invited, but the deadline for nonmember comments is past. Those submitting comments to NHPCO must do so by February 14 and comments submitted directly to NQF are due by February 16. The document is available at the NQF website at www.qualityforum.org. The NHPCO news release is at http://www.nhpco.org/files/public/newsbriefs/nb_020906.htm#inthenews3. (NQF Website; NHPCO NewsBriefs, 2/9)
NOTES
* The
*
* “Assessing the Appropriateness of Pain Medication Prescribing Practices in Nursing Homes” is an article in the February issue of the Journal of the American Geriatrics Society, online at www.blackwell-synergy.com (abstracts of articles are free). (Journal of the American Geriatrics Society, 2006;15(3):231)
* The March Journal of Clinical Nursing includes “The Intruder: Spouses’ Narratives About Life With a Chronically Ill Partner” and “Psychological Approaches to Pain Management, Part 1.” (Journal of Clinical Nursing, 2006;15(3):324)
* In view of the
right-to-die bill before the
Glatfelter Insurance
Group is the national sponsor of Hospice News Network for 2006. Glatfelter Insurance Group provides property
and liability insurance for hospices and home healthcare agencies through their
Hospice and Community Care Insurance Services division. Ask your insurance agent to visit their
website at www.hccis.com.