The Hospice e-News

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

Week of October 19, 2006

…a service of Florida Hospices and Palliative Care

 

 

WHO DECIDES ON CPR FOR THE GRAVELY ILL?

 

The New York Times, in “The Last Word on the Last Breath,” examines the legal and ethical complexities of giving or withholding CPR for gravely ill patients.  Physicians, patients and family representatives all face challenges.  The physician may “believe that medical judgment about whether CPR will be effective in a given patient’s case, and knowledge of the havoc it can wreak on a dying body, should prevail.”  The patient may or may not have made his or her own wishes known and is in no condition to now express them.  The patient’s representative may feel terrible guilt at refusing CPR and may mistakenly believe, from watching television, that CPR is usually effective and harmless. 

 

CPR was never intended to be “used routinely for very sick patients, for whom cardiac arrest is expected.”  Now in use for about 40 years, CPR, says the article, “can be successful in patients who have a sudden, unexpected heart attack or severe respiratory distress.  Research shows that the “long-term survival for hospitalized patients who are given CPR is about 15 percent” or less.  On television medical dramas, however, the long-term survival rate is 67%.

 

The article relates a story from Dr. Daniel Sulmasy, now an internist in New York.  As a young staff doctor, he was called upon to perform CPR on a 35-year-old man who had been in a persistent vegetative state for 15 years.  The man had pneumonia, septic bedsores, kidney failure and was losing weight in spite of a feeding tube.  Though he was now being in cardiac arrest, his family insisted that attempts be made to revive him.  A code was called, with all the attendant noise and activity, and Dr. Sulmasy began CPR.  Only after 15 minutes had passed was the patient declared dead.  Dr. Sulmasy remembers, “Kneeling on that bed, doing CPR, felt not only pointless, but like I was administering final blows to someone who had already had a hard enough life,.  Why was I forced to crack this person’s ribs?  Why couldn’t we have let the patient die in peace?’”

 

While the above example is extreme, the article says, “the question of who has final say over whether CPR should be attempted on a gravely ill patient -- the doctor, the patient or the patient’s representative -- is live and unsettled in law and medicine.”  Both states and hospitals have made attempts to clarify the issue, with a resulting hodge-podge of guidelines that are confusing even to some state judges.

*  New York has a law directly addressing resuscitation orders.  Even if the doctor believes CPR to be medically futile, if the patient cannot say that he or she does not want it and if the patient’s representative insists that it be used, the doctor must go to court to write a DNR order.

*  Texas has a “complex advance directive law that includes checks and balances” and “ultimately sides with physicians, immunizing them from litigation.”

*  Hawaii has legislation that gives “‘great weight’ to a patient’s ‘comfort care’ document,” a directive that spells out patient preferences.  But, even if the patient has specified no resuscitation and “‘the provider’s own conscience dictates otherwise, a medical professional may override the document.”

*  Oregon developed, and at least 13 other states now use, a form called Physician Orders for Life-Sustaining Treatment (POLST).  The form stays with the patient, whether at home or in the hospital and, if a patient is admitted to the ER, it can serve as a doctor’s order.

*  Many hospitals have, in the past few years, “quietly developed policies underscoring that doctors, not family members, should have the final authority to make these medical decisions.”

 

There is no question, says the article, that the goal of advance-care legislation and hospital ethics policies is to “create dignity and transparency in end-of-life decisions.  They are also, the article says, “intended to help insulate doctors from lawsuits.”  Dr. Robert V. Brody, chairman of the ethics committee at San Francisco General Hospital, says smaller community hospitals feel most of the burden, because they don’t have the “deep pockets” to fight lawsuits.  “Nurses and doctors hate it.  It’s a mess,” Brody said.  “The black and white of the law has significant limitations in the emotional gray area of decision making around serious illness and dying,” adds William H. Colby, lawyer for Nancy Cruzan.

 

“Many physicians and patient advocates say that casting these end-of-life conversations as adversarial needlessly provokes tensions.  Instead, they say, the focus should be on achieving a goal of end-stage care that both sides can agree on.”  The friction often arises when a patient who has not specified a preference about resuscitation is near death and the patient’s representative must make the decision.  Dr. Joseph J. Fins, author of A Palliative Ethic of Care, says “Doctors can fumble this most delicate of conversations.”  Sometimes, they even “foster” the disputes by indicating that one organ system may be improving, implying hope “when there is nothing but the grim reality that the patient will die.  Then all of a sudden we tell the family that it’s futile and we’re surprised that they’re surprised.”

 

Decisions about resuscitation are definitely stressful for patient representatives.  Dr. Sulmasy studied several cases where decision-makers refused to consent to DNR orders and found that the stress of the decision was comparable to that of surviving a house fire.  He thinks that the recent New York attorney general’s decision requiring doctors to go to mediation, or court, to order DNR over the objections of a family causes families even more stress.  “Before the attorney general’s opinion, we could say to some families, ‘This is it, your loved one is dying.’  And they would say, ‘All right, it’s your decision.  As long as it’s not on me.’  And they could get on with the task of mourning.”

 

Dr. Fins calls focusing on DNR orders “misguided.”  “DNR is a game plan for the last 15 minutes of your life,” he said. “By planning for those last 15 minutes, we’re distorting priorities.  Instead of talking about futility, we should be discussing what has utility, like pain management, comfort, closure.  Recasting the discussion has led to turning irresolvable dilemmas into problems that can be addressed.”  (The New York Times, 10/10)

 

 

PAIN NOTES

 

*  A study published in a recent Annals of Pharmacotherapy says that in spite of “an increased risk of cardiovascular adverse events,” coxib therapy may be superior in safety to nonselective NSAID therapy.  Patients who may qualify are those with “higher risks of GI complications, lower risk of CVEs, and in whom greater cost is not a restraint.”  A study reported in the American Journal of Cardiology said drugs that do not injure the gut, such as low-dose opiates or acetaminophen, may “minimize NSAID-medicated GI complications” in the elderly and in patients with a history of GI bleeding.  A second American Journal of Cardiology article said that acetaminophen “appears to have a more favorable cardiovascular and gastrointestinal safety profile” than NSAIDs in “individuals with an increased risk for cardiorenal effects from NSAIDs (e.g., the elderly, and those with hypertension, cardiac disease, or gouty nephropathy).”  (Pain & Central Nervous System Week, 10/9)

 

*  Researchers at a conference on pain recently held in Baltimore say that the brains of men and women are different, partly due to the role of sex hormones, and that men and women feel pain differently.  The Florida State University study found that women have lower thresholds and less tolerance for pain, but some studies report that men have greater anxiety about low-level pain.  A group of researchers at the conference are working to create guidelines to “guarantee consistency from study to study.”  Likely recommendations will include “documenting hormonal cycles when pain data is collected” and including the very old and the very young in pain experiments.  (The Capital, 10/8)

 

*  When the JCAHO implemented pain-management guidelines in 2001, Seattle’s Virginia Mason Medical Center went far beyond that minimum.  Innovations suggested by the staff included improvements in pain management, including a pain-service team that visits surgical patients twice a day and a nurse who checks pain levels every two hours and makes medications adjustments as necessary.  The Cleveland Clinic and the VHA have also “won accolades for their pain-management practices,” but “experts say many hospitals are lagging.”  Dr. Fred Burgess, president of the American Academy of Pain Medicine, says, “We’re now assessing pain, but it’s still not clear that we’re adequately treating it.”  (Newsweek, 10/16)

 

 

HOSPICE AND PALLIATIVE CARE NOTES

 

*  The patients in the palliative care program at New York’s Mount Sinai Medical Center are beyond “complicated,” Newsweek reports.  They are “exactly the sort of patients who often get lost in today’s cure-driven, hyperspecialized health-care system.”  They have multiple diseases, are chronically ill, “plagued by pain and other debilitating systems” and not likely to benefit from medical intervention for their illnesses.  Programs like Mount Sinai’s, with its director, Dr. Diane Meier, “are transforming the way U.S. hospitals care for the most seriously ill patients.”  The “engine” for that transformation is palliative care, and “when it’s done right, patients suffer less, families have more control, doctors and nurses have closer and more satisfying relationships with patients and families, and hospital costs are reduced even as the quality of care improves.”  (Newsweek, 10/16)

 

*  An article in the Monterey County Herald explains hospice and profiles Mari’Antonia Dudley, a 79-year-old hospice patient with COPD and congestive heart failure.  Dudley says that, while she’s not very active and spends most of her time reading or watching TV, she is independent and content.  She calls end-of-life care “liberating” and recommends it to anyone who is terminally ill.  (Monterey County Herald, 10/8)

 

*  David Work, executive director emeritus of the North Carolina Board of Pharmacy, writes of his wife Rebecca’s choice of hospice when faced with end-stage lung cancer.  Work says that she “maintained from the beginning that the quality of life is an important factor” and that she “suffered more from the treatment than she did from the disease.”  Rebecca died at Meadowlands Inpatient Hospice in Hillsborough five years after diagnosis, comfortable and “her dignity was intact.”  (The News & Observer, 10/10)

 

*  Oregon veterinarian Lynn Erdman had personal experience with hospice when her husband died seven years ago.  According to an article in the Oregonian, “She thinks the same kind of lessons apply to end-of-life issues for both human and animal companions.”  “Our society has a fear of death,” she says.  “We have to get away from the mind-set of, ‘I’m losing the battle with death.’  No, I’m choosing a loving relationship until the time is right to say goodbye.”  (The Oregonian, 10/10)

 

 

RESEARCH AND RESOURCE NOTES

 

*  An article in the latest issue of Ethnicity and Disease reports on a study of preferences for life-sustaining treatment that shows a clear difference between black patients and white.  Lead author, Dr. William Bayer, says that not only do blacks and whites have different wishes, but the wishes of black patients “are largely at odds with the prevailing ethic regarding end-of-life care.”  (Center for the Advancement of Health, 10/12)

 

*  A widely-reported study finds that the antipsychotic drugs used to calm agitated Alzheimer’s patients help very few of them and frequently have side-effects.  The NIH study suggests that most of the patients would do just as well on placebos.  This and another recent study reveal two problems in the regulation and use of psychiatric drugs.  The short-term trials “have limited value in telling doctors how patients will fare overall, or whether newer drugs are worth their higher cost.”  The other issue is “the extent to which physicians are prescribing and using medications in the absence of empirical data to guide them.”  (The Washington Post, 10/12)

 

*  Half of the registered nurses who responded to a recent survey reported “chronic interference of work with their home lives,” according to researchers at Wake Forest University School of Medicine.  Lead author Dr. Joseph Grzywacz said that such a large number is significant because studies have shown that the “intensity of work interference with family” undermines the health and well being of nurses and contributes to nursing dropout.  (World Disease Weekly, 10/10)

 

OTHER NOTES

 

*  From a discussion in a bar in Mexico, Annie Groer, staff writer for The Washington Post, got a lesson that would change her life.  Groer tells of visiting a nearby spa “to try to prepare emotionally and strategically for my father’s imminent death.”  At the spa, she met Fran Prolman, whose mother had just died.  Over drinks, Prolman uttered the words that “would become [Groer’s] road map and … mantra in the coming months – It is an honor and a privilege to help a parent die.”  (The Washington Post, 10/10)

 

*  In 2005, healthcare organizations had more voluntary employee turnover than companies in other industries.  The median healthcare turnover was 14.1%, compared to 10.6% in all US industries.  “Relocation, limited opportunities for promotion and pay scale” were cited by employers as primary reasons for turnover.  (AHA News Now, 10/12)

 

*  A new report from the Government Accountability Office (GAO) says, “Key information security controls were missing” from a communication network used by CMS.  The identified weaknesses “could lead to disruptions in services” to Medicare and Medicaid beneficiaries and that “sensitive, personally identifiable information ‘could be improperly modified, disclosed, or deleted.’”  The GAO says the system had no audit trails to determine who had used the network and “no reliable way to detect intrusions into [the] computers.”  (The New York Times, 10/8)

 

Thanks to Ann Jackson 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.