The Hospice e-News

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

Week of February 20, 2006

…a service of Florida Hospices and Palliative Care

SPOUSE HOSPITALIZATION AFFECTS MORTALITY

“Mortality After the Hospitalization of a Spouse,” an article in the current NEJM, reports on a study that examines the death of a partner after an elderly spouse has been hospitalized. The researchers, who looked at more than half a million couples who were Medicare enrollees in 1993, found that the partner of a hospitalized person over 65 may face an increased risk of dying within the next year, depending on the severity of the illness and the gender of the partner.

The authors note that the “bereavement effect” is the best-known example of an adverse effect on the health of a person in a relationship with another who dies. Similar to that, and usually studied separately from the bereavement effect, is “caregiver burden,” which focuses on the adverse health effects of caring for another who is ill or disabled. But looking at both phenomena together “provides an opportunity to assess the implications of spousal diseases with potentially variable lethality.”

In the sample used by the researchers, the average age was 75.4 years for the men and 72.9 for the women. The man was the older in 79.1% of the couples. Slightly over 90% of both sexes were white. Over a 10-year period, 74% of the men and 67% of the women were hospitalized at least once. During the same period, 49% of the men and 30% of the women died, and, in 18% of the couples, both partners died.

The researchers calculated a hazard ratio for the subsequent risk of death of a partner after a spouse’s hospitalization. The hazard ratio is directly related to the risk of death – a hazard ratio of 1.06 means that a partner’s risk of death is raised 6% by a spouse’s hospitalization, while a ratio of 1.18 means that the risk is 18% higher.

Increased risk of death varied by the diagnosis and the gender of the partner. Psychiatric diseases and dementia were far more likely to elevate the risk of death for a spouse than any form of cancer. Overall, men faced a hazard ratio of 1.21 when their wives were hospitalized and women a ratio of 1.17 when their husbands were admitted. Some of the other significant findings are as follows:

* Cancer: Men and women varied only slightly in their risk of death and most showed no elevated risk at all.

* Abdominal surgical disease: Men’s hazard ratio was 1.04 and women’s 1.03.

* Pneumonia: Hazard ratio was 1.06 for both sexes.

* Sepsis: Hazard ratio for men was 1.09 and 1.07 for women.

* Ischemic heart disease: 1.05 hazard ratio for men and 0.97 for women.

* Stroke: Nearly equal hazard ratio, at 1.06 for men and 1.05 for women.

* Congestive heart failure: 1.12 for men and 1.15 for women.

* COPD: Hazard ratio nearly the same – 1.12 for men and 1.13 for women.

* Hip or other serious fracture: 1.15 for men and 1.11 for women.

* Psychiatric disease: 1.19 for men and 1.32 for women.

* Dementia: 1.22 for men and 1.28 for women.

* All other diagnoses: Hazard ratio nearly the same and barely elevated – 1.02 for men, 1.01 for women.

The study also examined the effects of race, age and poverty status on spousal hospitalization. Only age affected men when a wife was hospitalized, while women were affected by both age and poverty. Race had only small differences in effect. Intensification of the effect of hospitalization was noted when the patient died within 30 days after hospital admission, with men experiencing a 22% increase in risk of death and women 16%.

The researchers were interested in whether the kind of caring for a patient made a difference in the hazard ratio for the spouse, hypothesizing that “the more a disease interfered with the physical or mental ability (regardless of the lethality of the disease), the worse the outcome for the partner.” The authors say, “Our results indicate that hospitalization for various diseases may indeed differentially affect partners.” Relatively speaking, cancer is not so burdensome regarding the spouse’s risk of death, and COPD and psychiatric illnesses rival dementia in the largest increase in risk of death. The rise in hazard ratio is similar for men and women across all causes of death.

There are two possible explanations for the association between hazard ratio and type of patient illness. “Spousal illness may impose stress on a partner, and … spousal illness or death may deprive a partner of social, emotional, economic, or other practical support.” Partners may make health choices, such as increased alcohol intake or bad dietary habits, which increase their vulnerability. But the stress may decrease within a relatively short time, while support from other sources may increase over time.

The authors note a cascading effect of “efforts to reduce disease, disability and death, since they can be self-reinforcing, and a decrease in the burden of such events in one spouse can have similar benefits for others.” More socially efficient, cost-effective healthcare might be achieved by considering the effects of such events on groups than by considering individual cases.

In conclusion, the authors suggest changes in the delivery of support services, such as the training and assistance of spouses as caregivers. Timely interventions, especially with certain diseases, “might optimally be matched to the riskiest times for partners – for example, just after hospitalization of the spouse.” And finally, “since seriously ill patients themselves care about the health of their loved ones, they have a substantial interest in mitigating any effects of their own illness on others.” (NEJM, 2006;354(7):719-730; Yahoo! News, 2/15)

SCIENCE BECOMING MORE ACCEPTING OF NEAR-DEATH VISIONS

An article in Deseret News explores the visions that dying people often have. By some estimates, as many as 25% of dying persons “see” deceased relatives shortly before they themselves die. Dr. James L. Hallenbeck, author of Palliative Care Perspectives, calls this frequency remarkable. He says another remarkable thing “is the fact that virtually always the relatives are, in fact, dead; visits by otherwise unseen living relatives are rare.” The next most frequent visitors, in Hallenbeck’s experience, are “guardian beings, angels and others… Often, they will communicate to the patient that their time (to die, crossover) has not yet come or some similar message. I have noticed no correlation between the appearance of such beings and religiosity in patients.”

Jennifer Hammargren, a chaplain for VistaCare hospice services, sees “a definable pattern of behavior” in terminally ill patients, “much of it involving a ‘life review’ that includes making amends with family and friends and a process called ‘faith questioning.’” Hammargren says that as patients arrive at a deeper spiritual understanding, they may “see” people in their rooms that they don’t know, occasionally including children who do not speak. Some describe relatives they’ve never met but have heard stories about, others see favorite pets and still others talk about seeing persons from their childhoods.

Hammargren has seen this “unseen realm” manifest itself “across the religious spectrum with Buddhists, Catholics, Jews, Christians, Unitarians, agnostics and humanists.” She believes we need to educate families to be “open and supportive” of such experiences of dying persons, asking, “How frustrating for a patient in the midst of this transition to try to talk to family members and be told they are nuts.”

Jean Miller, professor of nursing at the University of Rhode Island, says that academic programs have increasing numbers of classes on spirituality and death. Miller, who teaches such courses in the US, has also taught in Sweden, where church attendance is largely limited to baptisms, weddings and funerals. “They’re feeling the need to have this in their curriculum, yet they don’t know how to put words on it.”

Miller says she doesn’t know the real reason why patients see deceased relatives or friends. She says that some people think there’s a physiological reason, while others believe that dying patients really do see the otherwise unseen people in their rooms. Hallenbeck believes it to be an “altered state of consciousness,” and likens it to the functioning of a radio. “In normal wakefulness,” he says, “we function and interact on a relatively narrow and shared frequency that allows both transmission and reception of shared experiences. When patients at the end of life experience altered states, it is as if their radio frequency, their wavelength, has shifted,” and the radio dial has been slightly turned. The turn “allows the patient to experience both the ‘normal’ wavelength on which we coexist and yet receive signals on a wavelength that we cannot perceive. Such a patient might be perfectly aware of being in a hospital bed and of dying but be able to see and hear a deceased relative sitting in a chair next to the bed.”

Hammargren says she’s watched thousands of people die and believes “that we go somewhere and someone who loves us helps us go. This idea that you come by yourself and leave by yourself — we have people who love and cherish us as they welcome us, and it's the same when we leave here.” (Deseret News, 2/18)

PUBLIC POLICY NOTES

* The CMS final rule on hospice amendments went into effect on January 23, and Eli’s Home Care Week says “hospices need to get with the program or risk survey trouble.” New discharge requirements are implemented as separate “hospice amendments,” not as part of the hospice COP. Medicare will no longer stop payment as soon as the medical record questions the patient’s hospice eligibility, and one attorney recommends that “hospices should implement structured discharge systems for evaluating ongoing eligibility and determining the need for discharge – and for documenting those steps.” Hospices should “remember that they aren’t responsible for implementing post-discharge plans for patients, especially ones discharged for cause.” (Eli’s Home Care Week, 2/6)

* The New Hampshire House passed a bill that covers end-of-life decisions and allows mentally competent adults to designate healthcare proxies. Opponents of the bill expressed concern over the amount of discretion allowed to medical professionals in end-of-life decisions, while supporters argued that the bill “grants people complete freedom when it comes to defining their own scope of care.” (New Hampshire Public Radio Website, 2/15)

* The Center for Practical Bioethics and the CDC have initiated a project to develop an end-of-life model for public health departments. The Center “will identify or develop for the CDC a comprehensive end-of-life curriculum tailored to the public health community, an end-of-life resource manual for state health departments, a legislative tip sheet for state health departments, a list of key end-of-life contacts in each state, a template for an end-of-life web page and a dissemination plan.” (Medical News Today, 2/15)

* Representative Jan Schakowsky (D-Illinois) invokes Yogi Berra on President Bush’s budget – “déjà vu all over again.” Speaking to HHS Secretary Leavitt, Schakowsky said, “How can we tell the American public that this nation -- the greatest nation in the history of the world -- can afford to spend $133 million a day in Iraq but has to cut funding for hospice care and services for the mentally ill? How can we tell the American public that we need to extend and increase tax cuts for the already-wealthy who do not need them while freezing medical research and eliminating state programs to help the uninsured? … Americans deserve better. I hope that we reject this budget and enact priorities that will reflect public needs and strengthen the health and well-being of our nation.” (US Fed News, 2/15)

* Iowa’s Representative Mary Mascher (D) introduced House File 2425, which would allow assisted suicide in the state, to the state legislature. The bill would allow terminally ill persons to make a written request for life-ending medication, but requires physicians to educate patients about hospice care and to refer patients for counseling. A consulting physician would be required to confirm the findings of an attending physician. (Iowa Hospice Organization Legislative Bulletin, 2/17)

OTHER NOTES

* Finnish researchers have reported that teenage boys with good flexibility and teenage girls with good endurance strength may have less chronic pain as adults than their less healthy counterparts. The teenagers were evaluated in 1976, when their ages ranged from 12 to 17, and again recently. The study, reported in the British Journal of Sports Medicine, found that increased body mass increases the risk of “tension neck” and lower back pain for both sexes. (Yahoo! News, 2/15)

* Filmmaker Michael Moore wants victims of “healthcare horror stories” to contact him about possibly being in his next movie. Moore especially wants “victims of back-breaking hospital bills, HMO denials and exorbitantly priced pharmaceuticals” to respond. Neither the hospital nor the managed care industry is expecting good publicity from the upcoming movie. Richard Wade, spokesman for the American Hospital Association, says, “I don’t think he’s ever put a camera to a subject without any intent of blowing up something. I hope he doesn’t inadvertently destroy the thing that he says he wants people to have.” (Modern Healthcare, 2/13)

* Senior housing, a market niche aimed at the frail elderly, is “quite healthy now,” says the president of the American Seniors Housing Association. The number of companies offering such housing has shrunk since the early ‘90s and share prices have increased. The units are usually available only to those with significant funds to invest – from $300,000 to well over a million – and monthly fees can run into the thousands. (The New York Times, 2/15)

* Kansas City hospice singers Rebecca Stevens, Gigi Allison and Kari Dawson are recording a CD of favorite hymns and other songs on compact discs to be given to hospice families. They sing for patients at NorthCare Hospice, but, with 170 patients, they can only visit once a month. “The spiritual component for music can’t be underestimated,” Dawson says. “The majority of our patients, when they’re thinking about the end of their life, and the afterlife, they’re trying to resolve what they believe. Music is a big part of that.” (The Kansas City Star, 2/12)

* An article in Catholic Online says that after the death of Terri Schiavo, “reports of a dark side to the hospice movement are emerging,” and that “consumers need to be cautious before turning themselves or a loved one over to hospice care.” Stephen Connor, vice president of NHPCO, says that NHPCO has a “longstanding board resolution” opposing assisted suicide, that hospices neither hasten nor prolong dying, and that where assisted suicide is legal, hospices cannot legally discharge a patient who chooses assisted suicide. NHPCO’s position on artificial nutrition and hydration is that it is the patient’s right to choose, and the choice is usually made “in the context of a family system.” (Catholic Online, 2/17)

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.