The Hospice e-News
What the Media Said about End-of-Life Care This Week
Week of September 19, 2006
…a service of
CLINICIANS
GIVEN ADVICE ON LAST HOURS OF LIVING
“The Last Hours of Living: Practical Advice for Clinicians,” by Doctors
Linda Emanuel, Frank D. Ferris, Charles F. von Gunten
and Jamie H. Von Roenn, provides continuing education
credit for physicians and nurses. Topics
included are introduction to and preparing for the last hours of life,
physiologic changes, symptom management, typical last hours, pronouncing a
patient dead and notifying the family.
The program is online at www.medscape.com/viewprogram/5808?src=mp.
The authors say that advance
preparation and education of all persons who are around the patient are
essential if the end of the patient’s life is to be as positive as possible. They should “be knowledgeable about the
potential time course, signs, and symptoms of the dying process, and their
potential management.” Additionally, say
the authors, family members should “understand that what they see may be very
different from the patient's experience.”
The online course details the changes
during the dying process and describes the signs of each change. Examples of the changes are fatigue and
weakness, skin breakdown and wounds, decreased appetite and fluid intake and
heart and kidney failure. Neurologic dysfunctions include decreased levels of
consciousness and ability to communicate, delirium, respiratory distress,
inability to swallow, incontinence, pain, and the inability to close the
eyes. Uncommon events may include
asphyxiation, aspiration or a burst of energy just before death.
The authors list two “roads to
death.” The “usual” road includes
sleepiness, lethargy, obtundedness, a semicomatose state and then coma and death. The “difficult” road includes restlessness,
confusion, quivering or shaking, hallucinations, delirium, jerking, seizures,
light coma and then coma and death.
The authors suggest that families
need to know the signs that death has occurred. They are:
cessation of heartbeats and respiration, fixed and dilated pupils,
paleness of the body, drop in body temperature, muscle relaxation, sphincter
relaxation and possible passage of stool and urine. The eyes may remain open, the jaw may fall
open and bystanders may be able to hear internal fluids trickling.
Once a patient has died, say the
authors, both caregivers and family may need permission to spend time with the
deceased. A health professional, if
possible, should straighten the body and the bed, remove any machinery and
catheters and clean up any mess. Allow
as much time as needed for loved ones to say goodbye.
When communicating the news to those
who were not present at the death, the authors say, healthcare professionals should
try to avoid doing so by telephone. Provide a comfortable setting, break the news
gently and respond with empathy to any expressions of grief. Conclude the meeting with a plan for the
tasks that need to be done.
Local laws vary about what has to be
done to pronounce death. When a patient
dies at home under hospice care, the nurse may be able to make the
pronouncement. If the patient is not in
hospice, but the death was expected and the physician is willing to sign a
death certificate, there may not be a need to transport the deceased to a
hospital to be pronounced. Physicians
called to pronounce a death should find out if the family is present, if an
autopsy has been requested or is needed and whether there is any possibility of
organ donation. If the family is
present, the physician should explain why he or she is there, empathize with
the family and answer questions. The
article lists the tasks to be done in determining death and recording the event
in the medical record.
The
authors conclude with a number of key points to remember, some of which are:
* You only have one
chance to get it right when managing the last hours of someone’s life.
* Dying patients
often need skilled nursing care around the clock.
* Fatigue in a dying
patient is expected and, in most cases, should not be treated.
* Loss of
appetite and thirst are normal, and the ketosis which results from decreased
food intake can “lead to a greater sense of well-being and diminish pain.” Dehydration “may stimulate endorphin release
that adds to the patient’s sense of well-being.”
* Terminal delirium
(moaning, grimacing, agitation, restlessness, etc.) may be misinterpreted as
pain and sedating neuroleptics may be required.
* Avoid maintaining parenteral fluids, oropharyngeal suctioning,and removing the body prematurely.
The authors also suggest that only
essential medications be used, that the clinician be familiar with the signs of
the dying process, and that family and caregivers be drawn in as partners in
care. (Medscape Today, 8/28)
DEA
REVISES PAINKILLER PRESCRIPTION RULE
According to an article in The Washington Post, the Drug
Enforcement Administration recently rescinded a two-year-old policy that kept
physicians from writing multiple, post-dated prescriptions for opioids. Physicians can now write three 30-day
prescriptions, with two of the prescriptions having future dates, to be filled
at least one month apart. Two years ago,
the DEA revoked a similar policy and physicians began requiring patients to
come for monthly visits which “many doctors considered medically unnecessary
but essential to keep them out of trouble with the DEA.
DEA administrator Karen Tandy said
that the DEA had been wrong to revoke the prior rule, and had gotten more than
600 comments about it from doctors, patients and others. Howard Heit, a pain
and addiction specialist, says that Tandy’s actions were “a very positive step
forward in restoring that necessary cooperation between practicing physicians
and the DEA.” But Siobhan Reynolds,
founder of the Pain Relief Network, says that little has changed. “Ms. Tandy states here, as she has on many
occasions, that doctors need not fear criminal prosecution as long as they
practice medicine in conformity with what these drug cops think is appropriate. If that isn’t a threat, it will certainly
pass for one within the thoroughly intimidated medical community,” Reynolds
said. (The
RESEARCH
& RESOURCE NOTES
* A study
examining the outcomes of sustained-release opioids in hospice patients looked
at pain score, severity of constipation and the patient’s ability to
communicate with caregivers. Scores on
pain and severity of constipation were about the same for all three medications
– sustained-release morphine, oxycodone and transdermal fentanyl. Patients receiving transdermal
fentanyl had more communication problems than those
receiving the other two and also had a shorter length of hospice stay. (Medical
Devices & Surgical Technology Week, 9/17)
* When a person
is seriously ill, family and friends need to know how they are doing and
express concern, but the patient can’t keep everyone up to date. A website, www.thestatus.com,
is designed to do exactly that – provide “free, easy, secure, private web
communications for patients, family, friends.”
Patients can create their own personal pages in English, French or
Spanish, which may be password protected or left open for public view. Other languages will be added later. (The
New York Times, 9/12; The Status Website)
* A survey of parents whose children died in a
pediatric intensive care unit identified issues that they considered
important: complete and honest
information, easy access to staff, coordination of communication and care,
“real feelings” and support by the staff, “preservation of the integrity of the
parent-child relationship” and faith. An
abstract of the article, which originally appeared in the journal Pediatrics, is online at patient.cancerconsultants.com/news.aspx?id=38053. (CancerConsultants.com)
* The
reviewers of the new edition of Weiner’s
Pain Management are especially complimentary of the editors’ and authors’
coverage of complementary and alternative treatments of pain. The editors of the book intend it to be a
“first and last” source for information about pain management for most
clinicians, a goal that the reviewers say they don’t quite achieve. Better texts are available dealing with the
science of pain, the reviewers note, even as they
commend the editors and authors “for their enormous effort in providing a
unique work of such breadth.” (JAMA, 2006;296:1297-1298)
* According to Yahoo! News, a report from the Harvard School of Public Health says
that place of residence, race and income play “a huge role in the nation’s
health disparities, differences so stark … it’s as if there are eight separate
Americas instead of one.” Asian-American
women in Bergen County, New Jersey, typically live until they are 92, while
American Indian men in areas of
* In a review of Arnold Kling’s Crisis of Abundance: Rethinking How We Pay for Health Care,
reviewer Dr. Arnold S. Relman highly recommends the
book, in spite of disagreeing with the author on many assumptions and conclusions. He takes issue with Kling’s assertions that
“Prices in health care are related to costs of production, that we cannot have
health care that is both accessible and affordable while still insulating
consumers from its cost, that professional regulation mainly serves the
interests of physicians who wish to restrict competition, and that the best way
to control costs is to shift more responsibility to patients of all ages
through health savings accounts and insurance with high deductibles.” Most of all, Relman
says, Kling is “terribly mistaken in believing … that free markets can largely
replace government in protecting the public’s interest in health care.” But Relman agrees
with Kling on a number of other issues and was “attracted by a certain freshness
and directness in much of Kling’s argument.”
He “warmly recommends” the book “to general readers who want to
understand what economics has to say about health care.” (NEJM,
2006;355:1073-1074)
* In the
current issue of JAMA, Dr. Sharon K.
Hull reviews The Soul of a Doctor, a
collection of essays of Harvard medical students, in the current JAMA.
Calling the book “both captivating reading and an instructive cautionary
tale,” Hull says, “The student contributors write from their souls, providing a
frontline report on the process of acculturation into the profession.” She closes by saying, “The reader who expects to ever be a
patient in today's health care system or who is a physician at any point in the
developmental journey will find the stories in this volume at times heartening,
at times frightening, and always enlightening.” (JAMA, 2006;296:1141)
OTHER
NOTES
* In west
* At a recent
forum in San Bernadino, attorneys and physicians met
to attempt to understand each others’ point of view in end-of-life matters and
assisted suicide. Susan L. Penney, legal
counsel for the California Medical Association, says it’s important that
attorneys and physicians understand each other, particularly as medical
situations become more complex. In San Bernadino County, the county medical society and bar
association have been meeting every other year for twenty years to discuss
topics of mutual interest. (San Bernadino Sun,
9/14)
* In the
Catholic Health Association, 90% of the hospitals and 95% of its member health
systems have revised guidelines for “planning, measuring and documenting
community benefits.” The new guidelines
are intended to ensure that institutions meet the requirements for non-profit
organizations under the federal tax code.
US Senator Chuck Grassley (R-Iowa) asked the IRS to adopt the new CHA
guidelines “for calculating and publicly reporting community benefits and
charity care.” (Modern Healthcare, 9/11; Modern
Healthcare’s Daily Dose, 9/12)
* The lack of
available spots in nursing schools for new applicants is the driving force in
the nursing shortage in
* An article
about
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