Chicago Initiative Helps Improve Palliative Care, Increase Providers
Posted on Friday, November 28th, 2014 at 10:08 am by lifemediamatters
As millions of baby boomers age and face painful chronic diseases, a new initiative is working to bolster the number of palliative care providers in the U.S. The Coleman Palliative Medicine Training Program in Chicago aims to improve the quality of palliative medicine while increasing a trained national workforce of physicians, nurses and social workers.
In 2012, a two-year program was developed with funding from the Coleman Foundation of Chicago; about 30 nurses and physicians are now nearing completion of their training. Education consists of bi-annual continuing medical education (CME/CE) workshops, online learning, one-on-one mentoring and direct observation of a mentor’s practice in palliative care. The medical specialty helps treat the side-effects of disease and aggressive medical treatments. The goal is not cure, but symptom management.
Social workers, chaplains and advanced practice nurses are eligible to apply for Phase 2: Palliative Care Training for Interdisciplinary Providers, set to begin in 2015.
A major barrier to the expansion of palliative services is the lack of palliative physicians, according to the Center to Advance Palliative Care. In the U.S., there is only one palliative medicine physician for every 1,200 people living with a serious or life-threatening illness.
“I think the most important part of this whole program is being able to address the workforce shortage that we have here in Chicago, and across the country,” said Dr. Stacie Levine, co-director of the program and associate professor of medicine at the University of Chicago Medical Center. “We identify providers that can be adequately trained to provide palliative care in many different areas: inpatient, home and outpatient clinics. We are linking people together who have never met before, and they are identifying problems and building camaraderie.”
The program is free to selected participants, but it may soon need to adopt low-cost training options. Upon completion, trainees will receive a certificate acknowledging participation.
Dr. Sean O’Mahony, co-director and associate professor of medicine at Rush University Medical Center, called the program an organic network of medical providers who work and learn together.
“It is anticipated that within ten years we will have a workforce shortage in palliative care and hospice of about 14,000. Clearly, we need to be pooling our resources to try and train a wider array of palliative care people,” he said. “We thought we would go further if we trained people already in clinical practice.”
Trainee Ellen Norton, an advanced practice nurse working in Chicago’s suburbs, said she believes the program will help familiarize medical professionals with the benefits of palliative medicine.
“Palliative care is often equated with hospice care, but palliative medicine is for life and life transitions,” she said. “I have become friends with other colleagues who are experts in their fields. It has really helped my practice, because it allows me to maximize opportunities for patients and families, even if they are beyond my service area or need a different level of care in a different location.”
“Elderspeak”: Words Can Hurt
Posted on Wednesday, November 26th, 2014 at 4:07 pm by lifemediamatters
As the plot unfolded in the season premiere of HBO comedy, Getting On, I noticed the excessive use of “toddlerspeak” directed at elderly patients within the community hospital’s hospice unit. Whenever a physician or nurse was speaking to a patient, they tended to use baby talk—with a high pitch, lilting tone, longer space between words, elongated space around vowels, and simple, shortened words. When speaking to a baby or a toddler, such tones may help children learn language, provide amusement and get their attention. This show’s characters, however, were ones who had lived a long time; they were far older than the providers themselves. In one instance, a physician talked to a patient- a former physician- as if she were an infant.
Some patients suffered dementia, but others were perfectly capacitated. They had lived full lives and continued to enjoy meaningful lives—having raised families, pursued careers, taken care of themselves and others, and made societal contributions. However, they were being spoken to as if they were two years of age.
I wondered whether this blatant disrespect was only a television invention or something real. A New York Times piece in 2008 discussed how not just in medicine, but in many areas, some use terms like “sweetie” and “dear” when speaking with seniors. In a 2010 study and a 2009 study, researcher Kristine Williams found that seniors who are spoken to in “elderspeak” tended to be more resistant to care. Such speech signals that the senior is incompetent- accelerating a downward spiral and enhancing feelings of dependency.
Rather than viewing seniors as vulnerable and frail, we should temper that vision with thinking instead about the full life they have lived.
A physician at a large community hospital told me once that he often talked with senior patients this way. The physician never used terms like “sweetie” or “dear” outside of work, but he found himself using that language among the elderly he treats. His mentors did it, as well. “It’s just part of the culture,” this physician said.
Another friend from a family of physicians and attorneys told me about a loved one recently hospitalized after surgery. A nurse on duty told the patient that the “the boo boo” would hurt for a bit, and that she would have pain from “the ouchie.”
Another friend- a younger senior citizen- told me that she is always referred to as “baby” when she visits her doctor’s office.
During medical school, students learn the often difficult tasks of putting patients at ease and delivering bad news. However, I do not recall any curricula about how to speak specifically with seniors. Given the massive shortage of gerontologists, it is important for all providers- especially those in primary care- to learn to shun “elderspeak.” Such language decreases well-being, and it is demeaning. Patients who have lived full lives deserve to be addressed with respect, understanding and dignity. Infantilizing them through “elderspeak” is detrimental to the goals of medicine and to basic human kindness.
Rather than viewing seniors as vulnerable and frail, we should temper that vision with thinking instead about the full life they have lived. Given the prevalence of this phenomenon, it is something we must all be aware of and avoid.
Catholic Conference of Illinois Radio Hour
Posted on Wednesday, November 26th, 2014 at 1:15 pm by lifemediamatters
President Randi Belisomo on the importance of end of life discussions with family and friends. The Catholic Conference is currently updating its statewide advance directive materials, and Belisomo offers her perspective.
Striking The Balance Between Population Guidelines And Patient Primacy
Posted on Monday, November 24th, 2014 at 5:49 pm by lifemediamatters
Breast cancer is the second leading cause of cancer death among North American women. The American Cancer Society estimates that there will be 232,670 new cases of invasive breast cancer with 40,000 associated deaths in this year alone.
Routine screening mammography decreases the risk of death by about 15 percent; for every six women in her forties who die of breast cancer, one is saved by earlier detection with mammography. However, the research shows that 2,500 women over the course of a decade would need to be screened to prevent one cancer death. Given the low incidence of breast cancer in this cohort, the US Preventive Services Task Force (USPSTF) updated its population guidelines in 2009 to reflect findings. The new guidelines advised against routine screening mammography every one to two years in women ages 40-49. Instead, it advised screening every two years for women ages 50-74. This removed a full decade of routine screening from a woman’s calendar. To reiterate, the Task Force was not recommending against risk-based screening for someone in her forties, rather, just against routine screening.
These new guidelines were met with controversy and confusion, both from the medical community and lay public. Many women questioned the ability of “experts” to weigh potential benefits and harms of screening. Additionally, a deep mistrust intensified because the timing of these announcements coincided with news of healthcare reform, stoking potential fears that the change was a cost-savings measure.
But, here is where it is important to consider other factors in medical decision-making. The Charter for Medical Professionalism from the American Board of Internal Medicine defines three fundamental principles for physicians:
- The primacy of the patient: the health of my patient comes first
- Autonomy: patients have the right to make their own decisions, as long as these decisions are in keeping with ethical practice and do not lead to demands for inappropriate care
- Social Justice/fairness: the medical profession must promote social justice in the healthcare system, including the fair distribution of healthcare resources
Physicians have a few choices when sitting with 40-50 year old patients to discuss the appropriateness of routine screening mammograms. They can:
- Not recommend the mammogram, reviewing the evidence that routine screening is not supported for this age cohort.
- Order the mammogram, but warn patients that it is not likely to be covered by insurance, in which case she will bear the cost.
- Appeal the insurance company’s decision if coverage is denied. But, it should be explained to the patient that this course is not accepted if the physician would be expected to be untruthful.
Statistics show that the benefits of routine screening mammography for women under 50 do not outweigh the harms of false positives and unneeded biopsies. Some estimate that the cost of screening and the sentinel effect of false positives unnecessarily burden the healthcare system with $3.4 billion yearly. The question is: could these dollars be spent on better research and treatment that serves women of all ages? Others argue that only offering risk-based screening versus routine screening would miss many since women at high risk account for only about 10 to 25 percent of breast cancer diagnoses.
Every woman probably knows another diagnosed with breast cancer in her forties after a screening mammogram. How does a woman walk away from thinking that she may be that one in six saved by routine screening? The American Cancer Society and the USPSTF are currently re-evaluating their breast-cancer screening guidelines, particularly for women ages 40-49, since these guidelines can impact which procedures insurance companies and the state and federal healthcare exchanges will cover.
Women are not alone in facing change. Screening PSA guidelines and treatment protocols for men in their seventies have changed; MRIs were once used routinely for new low back pain screening. Routine colorectal screening is now limited to 50-75 year olds versus having no age limitation. Guidelines will continue to evolve as evidence-based screening and new technologies develop that benefit us all.
However, burgeoning healthcare demand and dwindling supply of financial and human resources are rapidly converging with those benefits. If guidelines are promulgated by respected professional organizations but not ubiquitous in execution, i.e., followed by all and for all, then how will the system provide fair equality of opportunity for all? Providing unnecessary testing, even if the cost is borne by the patient, distorts the healthcare system. Will it remain as it is today where those that have “get,” and those that don’t “get in line?”
An opinion piece in The New York Times by Drs. Pamela Hartzband and Jerome Groopman details these concepts of fairness, social justice and our responsibility for each other.
When a patient asks ‘Is this treatment right for me?’ the doctor faces a potential moral dilemma. How should he answer if the response is to his personal detriment [loss of patient relationship or loss of income]? Some health policy experts suggest that there is no moral dilemma. They argue that it is obsolete for the doctor to approach each patient strictly as an individual; medical decisions should be made on the basis of what is best for the population as a whole.
This is today’s reality. We do not have limitless resources. Where does patient primacy fit with social justice and fairness? Physicians are caught in this changing landscape. Do we have a moral responsibility for each other to assure we have equal access to basic medical services? If the answer is yes, then population guidelines are the platform for change. But, change is not easy….
The Charter for Medical Professionalism from the American Board of Internal Medicine
Annals of Internal Medicine. www.annals.org November 17, 2009.
Mammograms Save Lives.Criticism of breast-cancer screenings is more about rationing than rationality DanielB.Kopans May 22, 2014
How Medical Care is being Corrupted: By Pamela Hartzband and Jerome Groopmannov. NYT Nov 18, 2014
Alzheimer’s Caregiving Pushes Many Into Debt
Posted on Saturday, November 22nd, 2014 at 2:28 pm by lifemediamatters
Taking care of a loved one with Alzheimer’s disease is both emotional and expensive, and a new report from Caring.com shows exactly how much caregivers are affected by the disease (MarketWatch).
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