The Hospice e-News
What the Media Said about End-of-Life Care This Week
Week of October 3, 2006
…a service of
NEW REPORT CARD ISSUED ON STATE PAIN
POLICIES
The newest edition of Achieving Balance in State Pain Policy: A Progress Report Card (Second Edition) says, “Forty-one states
and the
Evaluations
of state policies were made earlier, in 2000 and 2003, and the current results
show continued improvement. No state
received a grade of A in 2003 but both
Aaron
Gilson, PhD, associate director of US policy research at the Pain &
Policies Study Group, says, “We’re seeing positive results, because healthcare
regulators have adopted policies encouraging pain management, palliative care,
and end-of-life care. Additionally, many
state legislatures have repealed restrictive or ambiguous policy language that
has prevented healthcare professionals from aggressively treating pain.”
John R. Seffin, PhD, American Cancer Society CEO, said, “The
results of PPSG's research show a very encouraging
improvement in state pain policies, but more needs to be done to effectively
address the national health crisis of undertreated
pain. States must effectively inform the
medical community about improved pain policies so people with pain can benefit
from them. Patients, health
organizations, healthcare professionals, regulatory officials, licensing
boards, and policymakers all have a role to play to promote a balanced approach
to pain control policy and practice.”
(AACPI Website; Joint Press Release by PPSG, The American
Cancer Society, LiveStrong, and The Susan B. Komen Breast Cancer Foundation, 9/27)
WITHDRAWING LIFE-SUSTAINING
SUPPLEMENTAL OXYGEN
In
“Terminal Withdrawal of Life-Sustaining Supplemental Oxygen,” in a recent JAMA, Doctors Scott D. Halpern and John Hansen-Flaschen
say that a case can be made for supplemental oxygen being a life-sustaining
therapy “for spontaneously breathing patients in whom pulmonary gas
exchange is so impaired that the needs of vital organs cannot be met
with ambient air alone.” New
technologies and increasing numbers of patients with cardiopulmonary disease
mean that more patients are being sustained with supplemental oxygen.
The
authors say, “Informed patients with decision-making capacity have
well-established rights to forgo any and all forms of
life-sustaining therapy. Although these
rights clearly extend to supplemental oxygen, requests to remove
this form of life-sustaining therapy raise difficult questions.” Some physicians may wonder whether they
should help patients remove the oxygen if the expected result of such action is
death. Or, if oxygen is removed, should
it be replaced with palliative sedation?
If palliative sedation is desirable, should distress be anticipated and
the sedation be administered before the oxygen is
discontinued, or only afterwards if there is obvious discomfort? The article says, “These and other concerns
may prevent some physicians from heeding requests for the withdrawal
of life-sustaining oxygen as readily as they may heed requests that
other therapies be withdrawn”
Balancing
the benefits and burdens of supplemental oxygen is one concern addressed by the
authors. Supplying high-flow oxygen has
gotten much easier with newer equipment and, in spite of some inconvenience,
“Oxygen is less burdensome than many other forms of life support.” Among its benefits are
the alleviation of dyspnea, sustained cognitive function in patients who have
severe hypoxemia when resting. However,
the possibility of pulmonary oxygen toxicity exists.
Physicians
may also be concerned about being accused of neglect if oxygen is discontinued. In some cases, the decision is made to
continue oxygen by a face mask or nasal cannula,
thereby offering some comfort to family and friends, even though the patient
may be sedated or even unresponsive.
Another
concern is whether a patient asking to have oxygen removed is competent to make
that choice. “Many illnesses for which
oxygen is used are accompanied by acute impairments of cognitive
function due to sleeplessness, hypercarbia, hypoxemia,
or the administration or accumulation of sedating drugs.” Additionally, the article says, if the
patient has difficulty communicating because of rapid breathing or dyspnea, it
may be difficult to test the patient’s capacity for decision-making.
The
authors write that giving the patient opioids and benzodiazepines after
withdrawing mechanical ventilators does not appear to influence the time until
death in ICU patients. They say that
giving such drugs “could easily hasten death among spontaneously breathing
patients who are only marginally able to sustain adequate ventilation.” The doctrine of double effect – outcomes that
would be ethically wrong if done intentionally are acceptable if they are the
unintentional byproducts of another action not intended to harm – may apply in
such situations. The Supreme Court accepts
it as such, but even physicians who also do so “may be unsure about how to
administer sedatives and analgesics in this situation. It is unclear what physiological changes
occur after abrupt replacement of high-flow oxygen with ambient air,
how patients experience these changes, and at what pace they occur.” The difficulties are compounded when the
patient is at home rather than in the hospital.
The
article suggests a four-step approach to decision-making, but note that
physicians may not be able to overcome all their concerns.
* Physicians should
assure everyone involved – patient, family, caregivers, other healthcare
personnel - that oxygen is a life-sustaining medical treatment. Requests for discontinuing it “should be
honored with the same judiciousness as requests to withdraw other forms of life
support.”
* Physicians should also assure themselves that
the patient is not influenced in the request by family members, treatable
depression or other circumstances such as economic concerns All other sources of distress should be
addressed and it may be helpful to obtain the services of a physician who uses
new technology for high-flow oxygen.
* Physicians must be
sure that the patient is mentally capable of making the request. Such requests should be made on at least two different
occasions and the patient should demonstrate knowledge of alternatives and
consequences. The patient should be able
to explain why the request is being made.
* Physicians should
make sure that patient, family and caregivers understand that it is very
difficult to predict a particular patient’s experience after oxygen is
withdrawn. The patient may become
unconscious or may show increased anxiety, distress and agitation. It should be also be made clear that if drugs
are needed for anxiety or distress, it is difficult to know how much to give –
too little and the patient may not get relief, or too much and oversedation may result.
Withdrawal
of supplemental oxygen is easier in a medical facility, but some patients may request
that it be done at home. The authors
suggest that a hospice nurse or physician participate, as they can provide
“more skilled assessment, titrated dosing of medications, comfort to others who
are present, and appropriate documentation of this
legitimate medical service.”
In
conclusion, the authors write, “Regardless of whether supplemental oxygen is
withdrawn in a hospital or at home, physicians should explain that
the patient’s major recourse in the event of uncontrolled distress
is to reapply their oxygen.
The plan can then be reconsidered in light of the experience
gained. False starts and ambivalence
have been described in the context of withdrawing dialysis and also
may occur after withdrawal of supplemental oxygen.” (JAMA,
2006;296:1397-1400)
NURSING SHORTAGE NOTES
* To address
* Carondelet Health Network and Mercy Health
System of Janesville, Wisconsin, along with large retail chains such as Home
Depot and CVS Pharmacy, offer “snowbird” employment to their northern employees
who want to spend the cold months of the winter in sunnier climates. Carondelet’s program
is five years old, and about 100 nurses, or 10% of its staff,
participates. An AARP spokesman says
that Carondelet and Mercy are the only two companies on AARP’s “Best Employers
for Workers Over 50” list who have snowbird programs but expects half the
companies on the list to have such programs within five years. (Time,
9/25)
* There is not
only a shortage of nurses, but of all healthcare personnel, an article in the San Bernardino County Sun says. Michael Wiechart,
of LifePoint Hospitals, says, “It’s the perfect storm
– a declining labor pool when the needs are increasing.” In
PUBLIC POLICY NOTES
* On October
19, HNN reported on a Washington Post article which said that
DEA had revised its prescription painkiller rule to allow physicians to write
multiple prescriptions as long as only one had the current date and the others
were future dated. A press release from
the DEA and other media reports clarify that the reported revision is a
proposal and that the public may comment on the proposed revision before
November 6. Check the “What’s New”
section, as of September 6, of the DEA website at www.deadiversion.usdoj.gov/new.htm. (DEA
Website)
* Effective October 15, Leslie Norwalk, a
member of the senior leadership team at CMS for the past five years, has been
named the acting director of CMS as Mark McClellan steps down. Mike Leavitt, HHS secretary, says, “She is a
nationally recognized expert on Medicare issues and played a central role in
the successful implementation of the prescription drug benefit and other
reforms to Medicare and Medicaid.”
Norwalk could serve for several months, or even years, until a permanent
successor to McClellan is nominated and approved. (AP,
9/25)
* The
OTHER NOTES
*
* Once the
reality of a loved one’s death has set in, most people, including children,
“move into a stage of mourning,” the Delaware
News Journal says. The author notes
that age is important in how children grieve. Those considering taking a child to a funeral
should let the child know what to expect, answer any questions before or after
the event, let the child sit with a calm adult during the service or let the
child create a picture or note to place in the casket. If the child chooses not to attend, let the
child honor the lost loved one by lighting a candle, saying a prayer or looking
through pictures and talking about the person.
(
* Several new
initiatives are designed to protect senior citizens from abuse.
* The health
of caregivers is in “a downward spiral” says a new study by the National
* A
“detailed study of 1,189 remarkably healthy 70-something men and women” has
found that certain combinations of lab tests were good predictors of death. Twelve years after the original study, which
was on successful aging, about half the sample was dead. Studies of the lab tests performed when they
entered the study found “trees” of death.
One “tree” combination of high adrenal hormone levels and high
C-reactive protein levels showed 28 deaths among the 30 people in that
“tree.” Most combinations which were
good predictors of death included “markers of immune activation” and high
levels of stress hormones. (WebMD with AOL Health, 9/18)
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