The Hospice e-News

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

Week of June 16, 2006

…a service of Florida Hospices and Palliative Care

 

 

 

STUDY SAYS FUTILE CANCER TREATMENTS ON THE RISE

 

An AP article entitled, “Doctors Say Futile Cancer Treatment Rising,” reports on a study led by Craig Earle of the Dana-Farber Cancer Institute and Harvard Medical School.  The study finds that treatment for cancer is often excessive, as well as too late in coming.  The study, which was presented at a recent meeting of the American Society of Clinical Oncology in Atlanta, explores the conditions in which people had succumbed to this illness.  The research involves the examination of the records of the care of 215,488 people who died of cancer in the nineties.  The study finds that, in many cases, patients underwent drastic procedures that were incapable of saving their lives and which, in fact, lowered the quality of life in their last days.

 

As illness progresses, the study reveals, patients are increasingly unwilling to give up hope for a cure, even when their treatment has clearly become untenable.  Physicians, as well, are not always likely to suggest hospice care to clearly terminal patients.  In fact, the study finds that while 10% of patients received chemotherapy in the last two weeks of life in 1993, 12% did so in 1999.  And the percentage is almost certainly higher today.  "There is a time to stop," explained Earle.  "It's sometimes easier to just keep giving chemotherapy than to have a frank discussion about hospice and palliative care." 

 

Admissions to intensive care units in the last month of life climbed from almost eight percent in 1993 to 11% in 1999.  Emergency room visits rose from about 24% to above 28%.  The study also reveals that the number of cancer patients entering hospice in the last three days of life rose from roughly 12% to 15%.  This, said one cancer specialist, is a waste of the hospice process, as the goal of hospice is to help terminally ill patients prepare for death. 

 

While it is clear that many patients are receiving too much treatment in the last days of life, another study details a paucity of necessary care for others.  The survey, which was conducted with nearly 700 primary care doctors in Wisconsin, finds that only 11% would refer a patient with advanced lung cancer to a cancer specialist and only 25% would refer someone with advanced breast cancer to a specialist.  Some speculate that this may be due to a general lack of knowledge among physicians regarding the latest advances in cancer treatments that give hope for many in the late stages of cancer.  (Associated Press, 06/02)

 

 

ARTICLE ADDRESSES CHANGES IN HOSPICE CARE

 

“The Changing Face of Hospice:  How it might affect patient care” is an article in the May Hematology and Oncology News and Issues.  Hospice programs across the United States, says author Wendy Walker, an oncology social worker, continue to struggle to find their place within the Medicare structure.  “According to the 2004 National Data Set from the National Hospice and Palliative Care Organization, the median length for a hospice patient of stay hovers at 22 days, unchanged from the previous year and a decrease from the 1995 high of 29 days.  Three weeks,” says the author, “is an abysmally short period of time to achieve the goal of a meaningful death experience for the patient and family.”

 

The current hospice structure demands that hospice care patients be diagnosed by their physician as having six or fewer months to live.  Due, at least in part, to this reluctance to quantify the likely immanence of the patient’s death, 35% of patients received seven or fewer days of hospice care, while only nine percent received close to the six months to which they were entitled.

 

With recent budget cuts across the board in social services, says Walker, it seems unlikely that the Medicare system will soon adapt itself to the needs of hospice.  For example, it is unlikely that Medicare will change its criterion for hospice benefits from its current “six months rule,” to allow access to patients with one year or less to live.  Instead, the article asserts, if hospice care is to thrive and provide improved services to those benefiting from it, hospices must adapt to the limits of this system.

 

The author shares some history of hospices.  Unfortunately, she says, since an investigation of fraud by the Office of the Inspector General in the late nineties, hospices have struggled to find their place within the Medicare structure.  The fraud investigation involved cases, mostly in Puerto Rico, where individuals had abused the hospice care system, claiming that their illnesses were more serious than they actually were and collecting hospice benefits when they were not as ill as the law required.  The aftermath of this investigation impacted hospices across the nation because it increased physician fear of being held accountable if their patients should “live too long.” 

 

As a result of these concerns, many “bridge” or “pre-hospice” programs began.  These programs avoid the limitations of the Medicare system, but they come with their own set of limitations.  The most significant of these limitations is that, while the underlying goal of hospice care is to improve the end-of-life and to allow patients to live their final months in as much normalcy as possible, many “bridge” programs provide extensive home care that requires that their patients remain in their homes, as opposed to going out to visit friends, see children’s baseball games, etc.  The article describes one such alternative--the Transitions Program of Williamstown, Massachusetts.  Here, volunteers provide services to patients who could not be otherwise covered under Medicare’s requirement that patients be certified as having six months or less to live. 

 

Patients who are admitted to hospice care for twenty-two days or shorter, says the article, require much more care than those whose stays are longer.  This results in higher cost per patient.  At least one insurance company, Aetna, has responded to this reality with expanded hospice benefits to encourage its patients to take advantage of hospice programs earlier in the course of their illness.  Florida now allows patients to be referred to hospice care by their physicians, with a prognosis of twelve or fewer months to live instead of the usual six.  This is important, notes the article, because doctors typically overestimate the amount of time a patient has left.  (Hematology and Oncology News and Issues, 5/2006)

 

 

PUBLIC POLICY NOTES

         

*  William Colby will speak at the Maine Hospice Council conference about the “right to die” in the United States.  Colby, author of the book Unplugged:  Reclaiming our right to die in America, will be revisiting the Terri Schiavo case, encouraging Americans to think about their end-of-life wishes and to make those wishes known to their loved ones.  Colby says that the rapidly aging baby-boomer population will soon be dealing with the question of life sustaining technologies, which preserve life, but not necessarily quality of life, on a massive scale.  He argues that political and spiritual leaders “must be a part of the public debate, but should not be allowed to dictate personal choice.”  Kandyce Powell, director of the Maine Hospice Council, notes that advance care directives, legal documents that specify a person’s end-of-life wishes, are important tools to insure patients’ dignity and quality of life in their last days.  (Bangor Daily News, 06/09)

 

*  The May 19 cover story of Medical Economics is titled “Doctors:  The new target in the war on drugs?”  The subtitle says, “Some critics think so, and they're blaming the DEA and other agencies for trying to make up for past failures.”  The government’s focus has “resulted in more physician investigations and high-profile prosecutions,” says the article, and this, in turn, has “sent a bigger chill through the prescribing community and exacerbated the epidemic of undertreated pain.”  The article traces the history of issues related to pain management and shares current concerns about oversight of pain management.  The article also cites court cases of physicians and refers readers to resources such as www.painandthelaw.org.  (Medical Economics, 5/19)

 

*  An article in the American Journal of Critical Care reflects on and is entitled “Questions concerning the goodness of hastening death.”  Author Lisa Day examines the use of logical and analytical approaches in addressing issues about dying and the role of the healthcare provider.  Day argues against “the entrenchment of hastening death as the most reasonable choice at the end of life.”  “Even when death is certain as the outcome,” Day says, “what happens to us in the process of dying remains unknowable and unpredictable.  We can never know if hastening death in order to avoid suffering is worth the trade-off of also avoiding the naturally dying process which may have turned out to be greatly important.”  (American Journal of Critical Care, 2006;15(3):312)

 

*  The “Family Health Care Decision Act” was first introduced in New York in 1993 and has failed to pass the Legislature on multiple attempts.  The legislation would establish “a mechanism for loved ones to decline futile or painful life-sustaining measures for patients who can’t decide for themselves.”  The current New York law allows no one to make end-of-life decisions for healthcare unless a patient has legally appointed a healthcare proxy.  An article in The Buffalo News also says that the current situation “denies many terminally ill patients the services of hospice….”  (The Buffalo News, 6/11) 

 

*  The American Pain Foundation and the Pain Care Forum, in cooperation with Representative Mike Rogers (R-Michigan), announced a Congressional briefing on the epidemic of pain in America.  The briefing will be held on June 13.  Details can be found by clicking on http://action.painfoundation.org/site/MessageViewer?em_id=2581.0&printer_friendly=1.  (American Pain Foundation)

 

 

OTHER NOTES

 

*  A program in California’s Central Valley helps ease reluctance of the region’s Hmong community to resort to Western-style medicine and works to bridge the culture gap between Hmong and native-born Americans.  The program, Healthy House, aims at informing the community’s traditional shaman about Western medicine, in the hopes that influential members of Hmong society might be able to encourage cooperation between practitioners of traditional Hmong shamanism and the area’s hospitals and Western medical tradition.  Any Hmong shaman that graduates from the program receives a hospital badge and gains the right to unrestricted access to hospital patients.  The shaman also encourages the Hmong community to take advantage of Western medicine to treat serious illness.  One important contribution that graduates make is to bridge cultural gaps between their community and the California medical establishment.  For example, among the Hmong, to say, “you have six months to live,” would be very offensive.  It would, in effect, be the equivalent of cursing someone. Doctors are learning to communicate such medical opinions in more indirect ways, so as to respect their patient’s cultural sensibilities.  (San Francisco Chronicle, 06/04)

 

*  The making of “farewell videos” is becoming a more pronounced trend among those facing a terminal illness.  Videos record terminally ill patients telling their life story, giving advice and saying goodbye.  Tatsue Stewart, 40, made a video for her young children before her death.  She left them with stories about how she and her husband met, advice based on her lifetime of experience and a testament to her Christian faith.  Some patients, says the article, might be hesitant to record themselves in such a way, feeling that this is an acceptance of death.  Others point out, however, that making the recording does not imply that death is necessarily immanent. Whether or not one does die, advocates point out, there is no downside to having the recording.  (The Oregonian, 06/08

 

*  A study, conducted by physician Daniel Johnson, reveals that fatigue is “common and disruptive” among hospice patients and “that fatigue assessments should incorporate measures of concurrent symptoms.”  Johnson and his colleagues will give a report on the findings at the September 2006 Congress on the Terminally ill in Montreal.  (PoPCRN, Summer 2006)

 

         

Thanks to Kathy McMahon and Jonathon Krutz 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.