The Hospice e-News

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

Week of March 13, 2006

…a service of Florida Hospices and Palliative Care

DR. SCOTT M. FISHMAN SPEAKS OUT ON PAIN ISSUES

PainAdvocacyCommunity’s “In the Spotlight” features an interview with Dr. Scott M. Fishman, immediate past-president of the American Academy of Pain Medicine and currently Chief of the Division of Pain Medicine and Professor of Anesthesiology at the University of California, Davis. The interview was conducted by Pamela Bennett, RN, BSN, Executive Director of Healthcare Alliance Development at Purdue Pharma LP.

When asked what one or two things people could do to affect the pain movement, Fishman offered the following suggestions:

* Everyone should join a consumer organization such as the American Pain Foundation, the National Pain Foundation, etc.

* Clinicians should work within their health systems to raise awareness about pain and to raise the standards of treating pain.

* Clinicians should also write letters to local and national newspapers and express opinions on the media coverage of pain.

Fishman sees three major issues on the horizon for the field of pain treatment.

* How is pain medicine going to be defined within the field of medicine – as fragments of other disciplines or an organized, discrete specialty?

* What responsibility does the physician have who treats pain? The holistic model of pain management conflicts with the way doctors are reimbursed for pain treatment.

* How do we deal with the war on drugs and the war on pain, two “potent public health crises clashing, with collateral damage on both sides”?

Fishman spoke at length on the effects of the DEA actions on pain treatment. The DEA withdrawal of the joint FAQ, Fishman says, was “a crystal clear sign that the words and the music weren’t going to the same song,” and “sent a tremendous chilling effect.” Physicians are asked to aggressively treat patients who are in pain, he says, but “the message comes back, ‘If you treat too aggressively, in a way we don’t agree with, and we’re not going to tell you what we don’t agree with, it’s not that we’re going to take your license away and punish you through the medical board, it’s that we’re going to take your license away but we’re going to charge you as a federal criminal.’”

Over the past 18 months, Fishman says, “We have seen a trend in the government of oversight of healthcare shifting from agencies that are responsible for public health, like the Department of Health and Human Services, to agencies that are responsible and invested in law enforcement, like the Department of Justice, and this is concerning because the reason we have public health agencies is to support the public health. … Law enforcement doesn’t have the expertise to manage public health.”

On the up side, Fishman sees several major gains. The passage of the NASPER law, the national prescription monitoring program, is one of those, in spite of controversy over whether clinicians, or only law enforcement officials, would have access to the data. The reversal of a $50 million appropriation that allowed the DEA to have a role in the FDA drug application process killed a program that “neither helped drug abuse nor helped undertreated pain” and was an example of “big brother watching.” That reversal was not “in itself such a huge triumph,” Fishman stated, “but what it says is that Congress is now understanding the difference between fighting the war on drugs and not causing too much collateral damage on public welfare.”

Two additional gains mentioned by Fishman were the Congressional hearings on pain and the recent US Supreme Court decision on physician-assisted suicide. Fishman himself does not believe in physician-assisted suicide, but says, “The problem is, if we criminalize physician-assisted suicide, who is going to want to be the last doctor holding the morphine syringe, even when a terminal patient needs it to prevent suffering. Who will want to be the one who does the right thing for a dying patient when all that stands between the treatment being viewed as criminal activity is law enforcement judging a physician’s intent.”

The article is online at www.partnersagainstpain.com. (PainAdvocacyCommunity, 2/2006)

STUDY PARTICIPANTS PREFER “EASY” ADVANCE DIRECTIVES

Researchers from San Francisco General Hospital and the University of California, San Francisco have created an easy-to-read, easy-to-understand advance directive form with culturally appropriate graphics that explain the text. The group submitted the document to the Institute for Healthcare Advancement (IHA) for the annual Health Literacy Awards. The group won a top honor.

IHA liked the document so well that it posted the California version on the IHA website, in both English and Spanish versions, at www.iha4health.org. A California study conducted to determine whether the form “would be associated with higher rates of patient acceptability and self-efficacy with treatment decisions,” when compared with a standard state form, found that the new form passed both tests, particularly for patients with language or literacy barriers. All participants, regardless of language or literacy level, preferred the new form.

Persons in other states who wish to modify the document for their state’s laws are welcome to do so, but IHA requests that they inform IHA and the SFGH-UCSF researchers by emailing gmayer@iha4health.org. (Health & Hospital Networks Online, 3/7)

OLDER PATIENTS ENTERING CLINICAL TRIALS MORE OFTEN

Historically, community oncologists have recommended that older patients seek palliative care rather than aggressive chemotherapy for their cancers. While almost half of lung cancer patients are over 70, only a third of them have participated in clinical trials. Older patients present challenges ranging from personal circumstances to medical complications, and researchers are only beginning to address these.

But rising life expectancies and the increasing numbers of the aging are likely to mean an increase in the numbers of older patients who want treatments and want to participate in research projects. A number of studies have examined the effects of chemotherapeutic agents on patients over 70, and the results could eventually change the standards of care for that age group. Some large cancer centers are adding geriatric oncologists to their staffs.

Even when elderly patients could benefit from trials, some physicians are reluctant to suggest that they participate. Transportation problems, spouses with dementia or other health problems and lack of money for good after-care can all cause patients to drop out of a study. While patients in their 70s can tolerate chemotherapy fairly well if they have no other chronic diseases, patients in their 80s suffer more side effects because their kidneys don’t flush out the toxins as efficiently.

Heart patients, on the other hand, don’t seem to hit the same age barrier. The Cleveland Clinic generally recommends simple bypass procedures for those over 80, but recently an 89-year-old had a successful quadruple bypass and several years ago, a 98-year-old barber had an aortic valve replacement. He lived to be 104. (The Plain Dealer, 3/7)

AGING BOOMER IMPACT MAY NOT BE SO BAD

A new federal study says that the economic and social impact of the “baby boomer sunset may be gentler than had been feared because of a significant drop in the percentage of older people with disabilities.” The Census Bureau’s report on the aging population found older Americans “more prosperous, better educated and healthier” and say that those differences from previous generations will “only accelerate” as the first boomers retire in 2011.

Data analysis showed that 26.2% of those who were over 65 in 1982 had a disability described as “a substantial limitation in a major life activity,” but that number shrank to only 19.7% in 1999. The downward trend is expected to continue.

There was some disagreement among experts on the reason for the drop, but most assumed that it was at least partly due to better education and a higher degree of prosperity than earlier generations. At least one researcher warned that the growing rate of obesity in the US may counteract the downward trend.

That was the good news. The bad news is that more older Americans are divorcing, “leading to concerns that broken families combined with low birth rates among baby boomers may create a situation where fewer people are available or willing to help care for their aging relatives, pushing even more of the burden onto government.” Also, older women and those who live alone still have fairly high levels of poverty. (The New York Times, 3/10)

NOTES

* A recent MedPAC staff report, including the results of a RAND study analyzing hospice data, indicates that the “first and last days of service seem to require much higher expenditures for the proper care of hospice patients.” MedPAC may suggest, “or at least study, the idea of increased reimbursement for those days of care.” The report is online at www.medpac.gov. (NHPCO Public Policy Update, 3/10)

* In “Caring at the End” in Commonweal Magazine, Paul Lauritzen asks whether the Schiavo case “helps us identify core moral questions about end-of-life decisions.” One question, which needs answering, he says, is, “Do we inevitably intend death when we remove a feeding tube from a PVS patient?” The article is online at www.commonwealmagazine.org. (Commonweal Magazine, 3/7)

* The 2005 DHS report on those who chose physician-assisted suicide under Oregon’s Death With Dignity Act is very similar to previous years. Thirty-eight people actually took their prescriptions in 2005, compared to 37 in 2004. As in previous years, most (84%) had cancer, averaged 70 years of age and had more formal education (37% had bachelor’s degrees). The report is available at www.oregon.gov/DHS/ph/pas. (Oregon Department of Human Services Website)

* Art Buchwald entered hospice when he decided he didn’t want any more dialysis. So far, he says, “Things are going my way. I am known in the hospice as The Man Who Wouldn’t Die.” He can eat anything he wants, while “most people who are not in hospice have to watch their diets.” Visitors come and Buchwald says, “Since it’s my show, we talk about anything I want.” Buchwald says that he’s “having a swell time – the best time of my life” as a hospice patient. (The Washington Post, 3/7)

* Patricia Neighmond interviewed Dr. Scott Fishman, head of the pain management program at the University of California-Davis, and Dr. Herbert Benson of Boston’s Mind/Body Medical Institute, for NPR’s Morning Edition. Fishman says that staying immobile with back pain is maybe the worst thing you can do. “These joints,” he says, “for them to clear out toxins and to feed themselves and to regenerate, need movement to move fluids in and out of them.” Benson says a meditative state can relieve stress and change the brain’s perception of pain. (NPR’s Morning Edition, 3/9)

* Myriad Genetics, Inc. is launching the largest-ever Alzheimer’s drug trial to see if Flurizan is effective in newly-diagnosed patients. Two additional companies, Quebec’s Neurochem, Inc. and Ireland’s Elan Pharmaceuticals, also have drugs in clinical trials. All three drugs are tailored to block production of beta-amyloid, which causes the plaque characteristic of the disease. (The Boston Globe, 3/11)

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.