The Hospice e-News

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

Week of April 24, 2006

…a service of Florida Hospices and Palliative Care

STUDY EXAMINES ROLE OF RELIGION FOR HOSPICE PATIENTS

A recent study looks at the “effects of religious orientation and spiritual activities on subjective well-being and death attitudes.” The study, which was conducted by Monika Ardelt, of the University of Florida, and Cynthia S. Koenig, of St. Mary’s College of Maryland, included 103 older adults in fairly healthy condition and 19 hospice patients aged 60 or older. “The Role of Religion for Hospice Patients and Relatively Healthy Older Adults,” published in Research for Aging, found that, after controlling for physical health and demographic variables, “a sense of purpose in life rather than religiosity had a direct positive effect on subjective well-being and a direct negative effect on death fear.”

Intrinsic religiosity has been described as “a meaning-endowing framework in terms of which all life is understood.” Intrinsic religiosity has a “strong direct positive effect on approach acceptance of death” and an “indirect positive effect on subjective well-being.” Persons who are extrinsically religious “use religion to their own ends” and may find it useful in attaining “security, social status, solace and social interaction.” In the study, extrinsic religiosity related positively to death anxiety and, in hospice patients, “negatively related to approach acceptance of death.”

The authors cite a number of studies showing that “the role of religion in an individual’s life increases in importance with age and is associated with a number of physical and psychological benefits.” The reasons for these benefits are less well understood. Older adults with physical handicaps may be less able to attend religious services and more likely to be depressed, while active older adults may receive numerous social and psychological benefits from attendance at worship and other services.

The belief is widely held, the article says, that “intrinsic religiosity ameliorates fears associated with death and dying.” But a number of studies have found mixed results – no relationship between religiosity and death anxiety, a negative relationship between religiosity and death anxiety in certain populations and, another showed, a negative relationship between religiosity and death anxiety, but a positive effect on death acceptance in older adults and terminally ill patients. The authors cite several experts as suggesting that the mixed findings may be due to flaws in instruments which measure religiosity.

A study by Wink and Scott found that those most anxious over approaching death were individuals exhibiting inconsistency between their beliefs about life after death and their religious practices. The article says that their results also were consistent with earlier studies which found that deeply nonreligious and deeply religious persons had less death anxiety than those who “give only some importance to religious beliefs and practices in their lives.” But Ardelt and Koenig say that it is not clear “if this holds true for older people at the very end of life.”

The authors say, “If an extrinsic religious orientation does more harm than good with regard to fear of death and does nothing to improve a dying person’s subjective well-being, it might be harmful rather than helpful to engage in discussions about religion and spirituality as a means of providing solace and divine comfort to an older person with a life-threatening illness. If the reason a person turns to religion remains extrinsic … and does not turn into an intrinsic commitment to a spiritual or religious life, religion in itself might not improve subjective well-being and reduce death anxiety at the end of life.”

In the current study, the hospice patients and the adults in the community did not differ significantly on race, “attitudes toward death, intrinsic religiosity, frequency of prayer, purpose in life.” Hospice patients did have lower scores on subjective health, subjective well-being and shared spiritual activities. The hospice patients scored higher on extrinsic religious orientation and were more likely to be male. Additional findings include:

* Subjective well-being correlated negatively with extrinsic religiosity and fear of death and positively with intrinsic religiosity, approach acceptance of death, a sense of purpose in life and shared spiritual activities.

* Fear of death correlated positively with extrinsic religiosity and negatively with purpose in life and shared spiritual activities.

* Acceptance of death and intrinsic religiosity were positively and strongly correlated with each other and also with purpose in life, frequency of prayer and shared spiritual activities.

* Extrinsic religiosity and shared spiritual activities were negatively related to each other.

* Purpose in life, frequency of prayer and shared spiritual activities were all positively correlated with each other. (Research on Aging, 2006;28(2);184-215)

VA MEDICAL CENTER OFFERS “HOME HOSPITAL” CARE

The VA Medical Center in Portland, Oregon, offers “home hospital” care that offers “sophisticated medical oversight – including nurse and doctor visits, X-rays and other tests – to patients willing and able to receive such care in their own homes.” The patients at home have an average length of “stay” of just over three days, compared to four days for in-hospital patients. The home program reduces the pressure on hospital beds for a hospital that often operates at full capacity.

In the current program, patients must have one of four diseases, meet certain medical criteria and have a safe environment at home. The patient is sent home with medicines and, possibly, oxygen tanks and a portable X-ray machine. A nurse visits daily and a physician is on 24-hour call.

A study initially reported in the Annals of Internal Medicine found significant savings in this hospital and two others. Home care cost $5,081, while in-hospital care for the same kinds of illness cost $7,480. Such programs are still a novelty and a representative of the American Hospital Association predicts that they will “have to guarantee the same level of safety, quality and continuity of care” that is available to in-patients.

The first home-hospital program in the US started at Johns Hopkins in 1996 with a two-year pilot program. The pilot seemed to show that the home care was “as safe and satisfactory as hospital care,” so the researchers signed up two managed-care plans and the Portland VA Medical Center for a 22-month study funded by the John A. Hartford Foundation. The findings reveal costs lower than those for hospital patients, shorter “stays,” fewer procedures ordered, less delirium on the part of patients and “greater overall satisfaction.” One managed-care program has dropped out because of staffing issues and the other has continued the program but has focused mainly on patients with congestive heart failure. (Wall Street Journal, 4/19)

RESEARCH AND RESOURCE NOTES

* The Administration on Aging has named May as Older Americans Month, with the theme of “Choices for Independence.” A number of materials are available for download from www.aoa.gov/press/oam/May_2006/Materials_Downloads.asp. (Administration on Aging Website)

* Last week, the Health Law Section of the Virginia State Bar, in conjunction with a number of healthcare organizations, sponsored an “Advance Directives Day.” Free educational materials and advance directive forms were provided by hospitals, nursing homes, hospices and other health care facilities for persons wanting to write down their end-of-life wishes. See www.vsb.org/sections/hl/advancedirectivesday2006.html for more information and copies of the forms. (The Roanoke Times, 4/16)

* A Palliative Ethic of Care: Clinical Wisdom at Life’s End, reviewed in the current NEJM, is “well worth reading, even by veteran clinicians,” writes reviewer Dr. Mellar P. Davis. Davis says, “The only mistake that [author Joseph J.] Fins makes is to limit his audience to medical students. This book is for physicians, nurses, and all others who care for those with life-limiting illnesses.” Fins divides the book into two sections – “Death and Dying in Context” and “Goal-Setting: A Strategy for Effective Palliative Care.” (NEJM, 2006;354:15)

* The US death rate dropped in 2004 in the biggest one-year decline since 1944. Nearly 50,000 fewer persons died in 2004 than the nearly 2.5 million who died in 2003. A statistician for the National Center for Health Statistics says, “We were surprised. We were scratching our heads.” Though the reasons for the drop were not clear, some suspect that a mild flu season may be one factor, along with better treatments and more access to health care. (USA Today, 4/20)

* The Open Society Institute (OSI) and the Pain & Policy Studies Group (PPSG), through the International Palliative Care Initiative, has announced the International Pain Policy Fellowship Program. The two-year program, whose goal is to “improve the availability of opioid analgesics for pain management in developing countries,” will include “training, mentoring and an in-country pain policy project.” More information is available at www.soros.org/initiatives/health/focus/ipci/grants/palliative/guidelines. (PPSG News Alert, 4/20)

PUBLIC POLICY NOTES

* The March 2006 Consumer Price Index for Medical Care has been released by the Bureau of Labor Statistics. The CPI factor is 333.8, “which should result in a $20,585.39 hospice cap for the 2006 cap year.” While not an official CMS announcement, the figure is the one that CMS will use in official calculations and NHPCO has released the figures “to help providers undertake preliminary budgeting and planning.” (NHPCO Newsbriefs, 4/20)

* Colorado has submitted a proposal to the federal government which would, if approved, give dying children and their families access to more in-home care and other services. The new plan would provide reimbursement for pediatric palliative care, counseling and respite care. One of the supporters of the plan is Laurie Totten, who lost a two-year-old daughter to leukemia. Totten says, “To ask a parent to stop trying to (cure) a child is not a fair question.” (Rocky Mountain News, 4/14)

* The District of Columbia Cancer Control Plan, released last week in an effort to “reverse some of the highest rates in the country, … calls for a major sustained effort to fix a system of prevention and care that is failing many of the city’s neediest residents.” The document “faults the D.C. government for underfunding screening programs for breast and cervical cancer and failing to fund prostate and colorectal cancer screening.” The report “criticizes the District’s ‘inequitable distribution of early detection programs, treatment and end-of-life aid and its failure to spend any tobacco settlement funds on health care and cancer services.” (The Washington Post, 4/20)

* Janet Pearson says, “It is perhaps fitting that on this Easter Sunday, there is some good news about dying in Oklahoma.” Attorney General Drew Edmondson (D) recently issued an opinion that residents may use a form other than the one required by the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act. Pearson says the law is as “complicated and confusing as its title” and welcomes Edmondson’s endorsement of the Five Wishes form. (Tulsa World, 4/16)

* A guest editorial in the Orlando Sentinel encourages persons to rethink the “terrible choice” that requires them to forego curative treatment in order to enter hospice, and to enroll in hospice earlier in order to reap its many benefits. Editorialist Richard Payne also urges that hospice eligibility be based on a patient’s needs for “aggressive pain and symptom management,” rather than on a prognosis of death within six months. (Orlando Sentinel, 4/20)

OTHER NOTES

* Americans for Better Care of the Dying is encouraging all Americans to “protect their right to decide whether or not they receive life-sustaining treatment in cases of terminal illness or serious accident.” A recent article says that 13 states are considering legislation which would mandate artificial feeding in the last days of a person’s life, which would “significantly limit a person’s personal freedom by creating a presumption for intervention and care.” Advance directives and healthcare powers of attorney, says the article, are “critical steps” in guaranteeing that a person will have the kind of end-of-life care they desire. (Law & Health Weekly, 4/29)

* Older Americans may be healthier than ever before, but the word hasn’t gotten around to many African-American and Latina widows, who “often spend their last years frail, poor and heartbreakingly lonely.” An article in the Sacramento Bee says that 40% of those two groups live alone and in poverty. Women 65 and older have average annual retirement benefits of $8,224, compared to $14,046 for men. Thirteen percent of older women and 7% of older men live in poverty, 78% of women 85 and older are widowed but only 35% of men of the same age. Forty percent of older women and 19% of older men live alone. (Sacramento Bee, 4/18)

* Room 217, named after the hospital room where Bev Foster’s father died, is a business founded by Foster. Room 217 makes and markets CDs with the goal of soothing dying patients and making their last moments easier. Foster chose the music for the CDs by asking 100 senior citizens what music they would listen to if they had one month to live. (Maclean’s, 4/17)

* A new organization in China, The Chinese Association for Life Care, will “address the end-of-life care for one of the world’s largest aging populations” and will “act as a regulatory organization in the field of end-of-life care.” Li Jiaxi, director of the association, says it will be composed of medical and legal workers and volunteers and will “engage in the development of end-of-life care, palliative care, gerontology research and healthcare for the elderly.” (Xinhua Economic News Service, 4/17)

Thanks to Jeff Lycan for contributions.

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.