The Life Matters Media Newswire aims to serve as a comprehensive portal of all news related to end of life decision making and care. We aggregate stories from other media outlets in one place- here, where you can access them easily. We also strive to produce original content covering stories we feel are receiving scant attention.
Half of older Americans visit emergency departments in their last month of life; 75 percent in last six months of life
Palliative medicine helps improve quality of life and reduces unnecessary spending on emergency care for the chronically ill, said Dr. Diane Meier, director of the Center to Advance Palliative Care and a professor of medical ethics at the Icahn School of Medicine at Mount Sinai. Meier was the keynote speaker for “Palliative Care: A Major Paradigm for Care Coordination,” a conference presented by the Illinois Hospital Association in Naperville Thursday.
Meier opened her lecture with the true story of an elderly couple struggling without palliative support:
Mr. B is an 88-year-old man suffering mild dementia and admitted to the hospital via the emergency department for management of back pain due to spinal stenosis and arthritis. His pain is an 8 on a scale of 10 upon admission– he receives 5 grams of acetaminophen (Tylenol) each day. He has been admitted three times in two months for pain, weight loss, falls and altered mental status due to constipation. His 83-year-old wife is overwhelmed.
“He hates being in the hospital, but what could I do? The pain was terrible and I couldn’t reach the doctor. I couldn’t even move him myself, so I called the ambulance. It was the only thing I could do,” Mrs. B told Meier.
Meier pointed out to an audience of palliative care nurses and other medical professionals that among Medicare enrollees in the top spending quintile, nearly half have chronic conditions and functional limitations, just like Mr. B. Most of the costliest 5 percent of Medicare enrollees (61 percent) suffer from similar conditions. Nationally, spending on dementia-related services totaled nearly $215 billion in 2010.
“The emergency department has become the modern death ritual in the U.S.,” Meier added, because half of older Americans visit the emergency department in their last month of life, and 75 percent do so in their last six months.
According to Meier, a palliative care strategy with geriatric support could have helped Mr. and Mrs. B manage symptoms more adequately, and it could even have helped them avoid some unnecessary hospitalizations. “What we need to do is get out of our taxonomy silos, specialty driven silos,” Meier said. “Because of the concentration of risk and spending, palliative care principles and practices are central to improving quality and reducing cost.” The costs of Mr. B’s four most recent hospital visits totaled several hundred thousand dollars. But the Bs did not do anything wrong, Meier said, because the medical system encouraged their situation. What else could they do?
Meier suggested more home and community-based services to help reduce the number of seniors who find themselves in situations like the the couple– lacking an able-bodied caregiver and without an easily accessible medical provider. “Staying home is concordant with people’s goals, she said. “Based on 25 state reports, costs of home and community-based long term care services are less than one-third the cost of nursing home care.” For example, in a study published in the journal Health Affairs, researchers determined that simply having meals delivered to a senior’s home significantly reduced the need for a nursing home.
As HealthDay News reported: “If all 48 contiguous states increased by 1 percent the number of elderly who got meals delivered to their homes, it would prevent 1,722 people on Medicaid from needing nursing home care.” Still, the U.S. lags behind every other industrialized nation when it comes to the ratio of social to health service expenditures.
Hope Brown, a nurse with the Carle Foundation Hospital in Urbana, IL, said she appreciated Meier’s attention to the costs of care and the need for social support. “It happens every day, situations like the Bs. We definitely need to get people into social services earlier, even meal delivery,” she added.
Overall, Meier urged medical professionals to “treat the person, not the disease.” Since most patients prefer to live at home and remain independent, (76 percent rank “independence” as most important, followed by pain and symptom relief, and staying alive last) palliative medicine should reflect those wishes.
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In an effort to help teach medical professionals how collaborative and coordinated care for the terminally ill results in improved patient outcomes and decreased hospital spending, Illinois-based Passages Hospice unveiled two new programs this week in celebration of National Palliative Care Month.
Passages was the only U.S. hospice chosen to participate in two new initiatives aiming to reduce hospital readmissions, the INTERACT program and Bridge Model. INTERACT (Interventions to Reduce Acute Care Transfers) provides detailed tracking and observations that could help prevent hospitalizations; Bridge uses community resources to ease patients’ transitions out of hospitals and back into their homes, said Kaitlyn Henderson, Passages communication manager. Both programs are backed by the National Institutes of Health.
“INTERACT is a system for skilled nursing facilities that trains them to look at the resident from every health care perspective, to look at their risks in advance instead of residents having to go to the hospital,” said Shelley Johansen, Passages chief marketing officer. “One of the reasons health care costs are where they are is because chronically ill elderly go in and out of hospitals.” The Bridge Model, Johansnen explained, places a licensed social worker within a patient’s hospital who follows him or her for 30 days after discharge to help ensure their well-being. “The whole goal is to keep patients at home or at a skilled nursing facility,” she said.
Nearly 120 medical professionals attended the unveiling of the programs at Chicago’s Carnivale restaurant; the event featured a flash mob of professional dancers in nursing scrubs. “It’s National Hospice Month, and we wanted to celebrate life,” Johansen said.
Passages Hospice Founder Seth Gillman told Life Matters Media that he works to keep his hospice progressive and cutting-edge because he remembers his own grandmother’s poor end of life care in a south Florida hospice. “She started constantly calling me and asking me for stuff and complaining about her care,” he said. “I saw that there were a lot of areas in the hospice delivery that were not really patient-centered, and it forced me to get involved.”
Gillman recounted memories from childhood, a time when his grandmother used to insist upon looking her best before welcoming visitors into her home. “But her hospice would not pay for makeup artists or beauticians for her, so she didn’t have many visitors while in hospice. I was like, ‘This is a person you’re dealing with- allow her to take visitors and look her best.’”
Now, Gillman says, every patient is like a grandmother. “Give patients everything they need, even that little extra that makes life worth living.”
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In 2012, 1.6 million Americans received hospice care; 36 percent died or were discharged within seven days of admission.
New findings published in the annual hospice facts and figures report show nearly 80 percent of hospice patients receive care for less than 90 days before dying. The median length of a hospice stay is only about 19 days, and the findings are both consistent with those of 2011 and troubling to study researchers.
The report, “Facts and Figures: Hospice Care in America,” was conducted by National Hospice and Palliative Care Organization. It provides data on hospice trends and updated information on the growth, delivery and quality of hospice care throughout the U.S.
“As hospice and palliative care professionals, we need to continue reaching out to patients and family caregivers to help them understand all the benefits that hospice care brings,” said NHPCO President and CEO J. Donald Schumacher, Psy.D in a press release. “As part of our ongoing engagement efforts, we must continue our efforts to reach communities that are under-utilizing hospice care.”
Hospice is care that aims to provide comfort and pain management rather than aggressive treatments– usually only for terminally ill patients with six months or less to live. It is most often used when curative treatments are no longer effective. Cancer remains the most common diagnosis for patients seeking hospice; 37 percent of enrollees are cancer patients.
Sixty-six percent of patients who receive hospice benefits remain in the place they call home, whether it be a private residence or nursing home, unchanged from 2011. The gender divide between hospice patients also remains unchanged; 56 percent of hospice patients are female.
Since the founding of the first American hospice in 1974, more than five thousand hospice programs have opened throughout the U.S. The Medicare hospice benefit, enacted by Congress in 1982, remains the predominant source of payment. Eighty-four percent of patients receive coverage through the benefit.
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Although surrogate trust in ICU physicians is an important factor in avoiding conflicts during end of life decision-making, a team of researchers has determined that nurses play a critical role in fostering trust between physicians and patient surrogates.
Seeking to better understand how the lack of confidence between surrogates and clinicians affects shared decision-making, the Northwestern University researchers, led by Paul J. Hutchison, M.D., conducted in-depth, semi-structured interviews with 30 surrogate decision-makers in a closed-model medical intensive care unit. The surrogates then answered questions about their overall ICU experiences and their level of trust in clinicians.
According to the transcribed interviews, surrogates prefer the care and relationships of ICU nurses to physicians. “The constant activity and focus of nurses in patient rooms strengthens trust and reassures surrogates that their loved ones will receive good care even at times when they are not present,” the submitted abstract read.
However, the reputation and name of the medical facility in which a patient is being treated also affected surrogates’ levels of trust in physicians.
A hospital with a more exclusive, higher-end image caused some surrogates to “blindly” trust their loved one’s care. According to Hutchison, patients and their surrogates even value “blunt and non-sugar-coated” talk with physicians, as long as they can still identify with the humanistic qualities of the doctor.
Their research was presented as a poster entitled “Dimensions and Mediators of Surrogate Trust in the Intensive Care Unit,” and displayed at the John and Gwen Smart Symposium at Northwestern University’s Buehler Center on Aging, Health and Society.
Hutchison and his team provided three recommendations for improving trust: (1) intensive care units should provide plenty of nursing and support staff; (2) physicians should mind their tone and style when communicating with surrogates and a patient’s loved ones; (3) interventions aimed at increasing trust should be role specific, because surrogate expectations are different for physicians and nurses.
“I think there is an incredible amount of stress with surrogates in the ICU. They are more anxious and want to contribute,” Hutchison said. “But clinicians often don’t appreciate their hardships or show enough sympathy.”
When asked what he would like his future patients and their surrogates to know, Hutchison replied: “I’d like them to know that we really have a genuine concern for their needs, but sometimes we need assistance. Tell us your needs as a decision-maker.”
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Indiana Hunter’s Decision To Stop Life-Sustaining Treatments Spurs Discussion | Chicago End-of-Life Care Coalition Hosts Fall Benefit | Oncologists Present ‘Top Five List Of Dont’s’
The American Society of Clinical Oncology has highlighted five categories of tests, procedures and treatments that are commonly used on terminally ill patients despite their clinical values not currently supported by available medical research. The list is part of the American Board of Internal Medicine’s (ABIM) annual Choosing Wisely Campaign.
“As physicians, we have a fundamental responsibility to provide high-quality, high-value cancer care for all of our patients,” said Dr. Lowell E. Schnipper, lead author of the article and chair of ASCO’s Value of Cancer Care Task Force.
“That means eliminating screening and imaging tests where the risk of harm outweighs the benefits, and making sure that every choice of treatment reflects the best available evidence. By providing evidence-based care, we not only help our patients live better with cancer, we also assure they are getting high-quality care that will deliver the greatest possible benefit for the cost.” Nearly 140 oncologists voted on the list’s items.
The Top Five List:
• Do not give patients starting on a chemotherapy regimen that has a low or moderate risk of causing nausea and vomiting anti-emetic drugs intended for use with a regimen that has a high risk of causing nausea and vomiting.
• Do not use combination chemotherapy (multiple drugs) instead of chemotherapy with one drug when treating an individual for metastatic breast cancer unless the patient needs a rapid response to relieve tumor-related symptoms.
• Avoid using PET or PET-CT scanning as part of routine follow-up care to monitor for a cancer recurrence in patients who have finished initial treatment to eliminate the cancer unless there is high-level evidence that such imaging will change the outcome.
• Do not perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years.
• Do not use a targeted therapy intended for use against a specific genetic aberration unless a patient’s tumor cells have a specific biomarker that predicts an effective response to the targeted therapy.
“The Top Five List is a start,” said LMM Co-Founder Dr. Mary F. Mulcahy, a clinical oncologist with Northwestern Memorial Hospital. “In addition to the rest of the Choosing Wisely campaign, it is bringing attention to some of the excessive expenditures in medical care. It begins to change the conversation around medical care to include the overuse or misuse of medical tests, and the harm/benefit of medical tests. This may very well lead to improved end of life care as patients will be more familiar with the limitations in medical care.”
According to the study researchers, the rising cost of health care continues to threaten the long-term vigor of the U.S. economy, and answers are needed. “Cancer care, although a relatively small fraction of total U.S. health care expenditures, is expected to increase from $125 billion in 2010 to $158 billion in 2020,” the study reads.
“Hopefully evaluations like this will continue and will result in less waste in medical care,” Mulcahy said.
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Daniel Gaitan serves as a content producer...More