Three Illinois End of Life Care Organizations To Merge

Three Illinois End of Life Care Organizations To Merge

Posted on Monday, April 6th, 2015 at 10:49 am by lifemediamatters

Three Chicago-area end of life care organizations plan to merge to become one of the largest nonprofit hospice providers in the Midwest.

Under terms of the new agreement, Chicago-based Horizon Hospice & Palliative Care, Barrington-based JourneyCare and Glenview-based Midwest Palliative & Hospice CareCenter will operate as a single entity. When combined, the organization will employ more than 800 health care professionals and care for thousands of patients annually. It will be the largest nonprofit hospice provider in the state when the deal closes on June 1.

Sarah Bealles was selected to become president and CEO of the combined agency

Sarah Bealles was selected to become president and CEO of the combined agency

“The idea of our organizations coming together in a more formal way has been discussed going back as far as 2006. At that time, we came together and formed a hospice collective, which began working on group purchasing. Over the years, the relationship deepened and we began working together to share best practices,” said Sarah Bealles, who was selected to become president and CEO of the combined agency, moving from her current role as president and CEO of JourneyCare.

Bealles said she believes the partnership will “only enhance their services” and allow for a wider away of programs and resources for seriously ill patients and their families. She hopes to maintain a strong sense of community and teamwork in the new organization.

“We have been very intentional about communicating with our patients and families on this. Their main concern is going to be their team that takes care of them– they develop very deep bonds with their teams, and the team assignments won’t change. We’ll be very careful as we go through future plans to integrate our teams,” she added. “It’s not like we’re becoming a national chain here, we believe with our current size, that we can still very much maintain a sense of family and culture, although it will be more challenging. The way we do all staff meetings, for example, we’ll probably not be able to get everyone together in the same way that we have before. We’ve talked about rotating sites and video conferences, so some of the mechanics of it will change.”

The combined organization will be led by a newly elected 18-person board, with six members chosen from each provider’s current board, according to a statement. Up to four additional independent voting members may also be chosen from outside of the organizations within a year after closing. Mary Runge, CEO of Horizon, and Jamie O’Malley, CEO of Midwest CareCenter, will remain in active roles throughout the transition.

Collectively, the three organizations have five inpatient hospice centers and six offices in the greater Chicago area. These facilities will remain fully operational, Bealles said, and the new agency’s corporate functions will be dispersed throughout its existing offices.

All existing partnerships are expected to remain in place, and all employees will be transitioned into new or similar roles within the new agency. Some administrative employees will be transferred to new offices.

HOSPICES“The majority of our staff, roughly 70 percent, are clinical, so the patient-ratios are where they need to be. Our clinical service delivery will continue to be regional,” Bealles added. “On the administrative side, there is a little more to work through. Some people will be asked to change their office location… It’s very manageable to do this without letting anyone go.”

The new agency’s name is expected to be announced by fall, and a consulting firm has been hired to help with rebranding.

“I think what we’ve created here is really an opportunity. It’s an opportunity for us to deliver something that I’ve never seen, or as comprehensive as what we’ve put together, in terms of providing better care to people with advanced illness,” she added. “We’re positioning ourselves really to be able to innovate as health care changes and continue to live our mission, but understanding that we may need to deliver our services differently as health care evolves.”

The combined companies’ revenues in 2013 were about $81 million, the equivalent of about 15 percent of the $548 million spent on hospice care that year in Illinois, according to research organization Hospice Analytics.

In recent years health care companies have been consolidating as Medicare reimbursements become lower and providers face cuts. With an increasingly aging population, the demand for hospice and palliative care will likely rise.


Reimburse Doctors For Helping Patients Plan End Of Life Care, Experts Say

Posted on Monday, March 23rd, 2015 at 6:44 pm by lifemediamatters

This piece was first published in Reuters Health. President Randi Belisomo is a contributor.

Physician incentives are needed to improve end of life care in the U.S., health experts said Friday at an Institute of Medicine (IOM) forum.

The forum convened at the National Academy of Sciences to discuss action on the recommendations of the IOM’s seminal fall report, Dying in America.

Victor Dzau

IOM President Victor Dzau

“Our current system is not equipped to deal with these challenges,” said IOM President Victor Dzau, citing a rising number of elderly with multiple chronic illnesses, too few palliative care services to keep pace with demand, and time pressures that keep providers from having conversations with patients about end of life preferences and values.

“We need to make sure that healthcare providers do not shy away from these discussions,” said Senate Aging Committee Chairman Susan Collins (R-Maine). “Until we solve the reimbursement issue, I don’t think we are going to make true progress.”

Senator Mark Warner (D-Virginia) said he regretted his failure to talk with his mother, an Alzheimer’s patient, about the end of life care she desired. He lost the opportunity to have this conversation when she lost her ability to communicate, nine years before her death.

“I was an informed citizen at the time, the governor of Virginia, and yet my family and I didn’t have a full understanding of everything that was before us,” said Warner, indicating that he will reintroduce a measure to create a Medicare and Medicaid benefit for end of life planning.

Dr. Atul Gawande

Dr. Atul Gawande

When people fail to plan for end of life care, they may suffer through ultimately futile, invasive and often unwanted treatments, advocates say. Surgeon and author Atul Gawande detailed the “medicalization of mortality” occurring over the past several decades, noting that the most likely time for Americans to undergo surgery is the last week of life.

“We fail to recognize that people have goals and priorities in their lives we need to serve besides just living longer,” Gawande said. “The way you learn what people’s priorities are is by asking.”

Last year, the Centers for Medicare and Medicaid Services rejected an American Medical Association request to create a billing code for doctors to use when they spend time helping patients plan for future care. Patrick Conway, chief CMS medical officer, said the coding would be considered this year.

If physicians will be reimbursed, work remains to ensure the quality of care patients receive. “Metrics in this area are not easy to develop, but they’re not impossible,” said Christine Cassel, president of the National Quality Forum. “Payers need to know they are paying for the right kind of care.”

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Fearing Lawsuits, Some Physicians Provide Unwanted Medical Treatments To Seriously Ill Patients

Posted on Friday, March 13th, 2015 at 7:33 am by lifemediamatters

Nadia Sawicki

Nadia Sawicki

Physician decision-making is often tinged with concern for legal liability, causing some doctors to provide unwanted, often futile, medical treatments to patients nearing death, said an attorney and bioethicist to a crowd this week at the University of Chicago’s MacLean Center for Clinical Medical Ethics.

“Clinical challenges at the end of life are often about when to say ‘we’re done,’ about how far to go in treating patients who are unlikely to survive, or who are unlikely to recover,” said Nadia Sawicki, an associate professor of law at Loyola University Chicago. “As a legal matter, patients and their families typically have the ultimate say in decisions. Physicians and other health care professionals serve a vital role in guiding those decisions and making recommendations based off their professional expertise.”

Physicians ought not be in a position where the threat of legal liability causes them to violate their own ethical convictions.

Experienced physicians are usually more realistic about a patient’s prognosis or disease trajectory than family or close friends. But in some cases, Sawicki said, physicians fearing future litigation from family members for withdrawing medical treatments will push for continued, often aggressive, therapies.

“Evidence shows that in many, if not most cases of futility conflicts, health care providers and institutions ultimately do continue to provide treatments requested by families, even if this violates their own professional convictions about medical practice and medicine,” she added. “Physicians ought not be in a position where the threat of legal liability causes them to violate their own ethical convictions.”

Health care providers are more likely to face litigation for withdrawing treatments than for providing them, a symptom of the “contradiction” in American law, Sawicki said. Even though Americans have the right to medical self-determination, including the freedom to decline life-saving medical interventions, tort law does not recognize prolonged life as a legally compensable injury. However, some courts are now reconsidering that position and allowing claims to proceed.

Nadia Sawicki

Nadia Sawicki on tort law and end of life care

“Patients can be harmed, as much by receiving unwanted care, as by having care withdrawn,” she added. “Courts are more effectively balancing tort law and consent. In a sense, with the threat of liability more balanced on each side, U.S. physicians should feel encouraged to do what they think is best in accordance with professional ethics and standards of care.”

She went on to list a handful of academic studies exploring the motivations of some medical providers for ignoring patient or surrogate wishes. According to a 1995 study published in the American Journal of Respiratory and Critical Care Medicine, 34 percent of physicians continued life-sustaining treatments, despite patient wishes that they be halted.

“We conclude that physicians do not reflexively accept requests by patients or surrogates to limit or continue life-sustaining treatment, but place these requests alongside a collection of other factors, including assessments of prognosis and perceptions of other ethical, legal, and policy guidelines,” researchers write. “While debate continues about the ethical and legal foundations of medical futility, our results suggest that most critical care physicians are incorporating some concept of medical futility into decision making at the bedside.”

A 2012 survey led by Dr. Ferdinando Mirarchi, medical director of the Department of Emergency Medicine at the University of Pittsburgh Medical Center, determined that 20 percent of physicians would defibrillate a patient with a clear do-not-resuscitate order.

“There are times where we have seconds to minutes to act,” he said. “In those instances, when a document gets misinterpreted, someone lives or someone dies.”

Mirarchi’s findings were echoed in a recent study published in BMC Medical Ethics. Fifty-two percent of physicians agreed that the risk of liability is lower when keeping someone alive against their wishes than in mistakenly failing to resuscitate.

“When confronted with a spouse’s wishes that conflict with those provided by the patient’s (advance directive), over half of respondents considered the threat of legal liability as important or very important to their decision,” researchers write.


Reflections Of Med Students Upon First Patient Deaths Prove Valuable To Experienced Clinicians

Posted on Thursday, February 26th, 2015 at 11:03 am by lifemediamatters

Medical students caring for the terminally ill must learn to be both sensitive and resilient to cope with workplace stress and provide comfort to patients and their families, said a bioethicist to a crowd this week at the University of Chicago’s MacLean Center for Clinical Medical Ethics.

Mark Kuczewski

Mark Kuczewski

“Being present to patients and families is a complex skill of being personally engaged, available and open to particular needs,” said Mark Kuczewski, director of the Neiswanger Institute for Bioethics and Health Policy at Loyola University Chicago. “There is a struggle to be desensitized enough to do one’s work, but sensitive enough to deal with the particular patient and family.”

Kuczewski, in collaboration with other end of life care experts, asked 68 students completing clinical clerkships to reflect and write about their experiences caring for dying patients. Researchers then mined answers for common themes.

Many students noted a lack of discussion about care options for patients approaching death, Kuczewski said, because clinicians were too immersed in details of immediate treatments.

Not once did my team mention or consider that Ms. W was in the process of dying. I did not hear any talk about end of life care, so I didn’t think it was necessary to talk about this with the family. I spent a lot of time with them (the family) answering questions…She (patient’s sister) was very suspicious and felt like she was not getting the whole story. I don’t think she did get the whole story either.

Other students said they were shocked by the suddenness of death and lack of acknowledgement by nurses and attending physicians.

I didn’t even get a chance to say goodbye to the family. Before I even realized what had happened, the family was gone, the patient removed from the list and my next patient waiting for me to take care of them. The team didn’t make any comments about her death that morning, and everything seemed to continue and move on as if nothing had happened…I initially did not know what I wish had happened, but the way the situation ended lacked any closure for me.

Kuczewski identified common “pledges” from students from which veteran clinicians could benefit. The most common commitment: to remain aware of and sensitive to the needs of families, and not allow needs to go unaddressed.

All I can do is take from this experience and move forward by being there for others when the time comes.

I will never let that be OK again.

The second most common pledge was to refer families to pastoral care.

If I am not available to be present with those grieving, I will make sure that other qualified people are, so these people are not alone.

On a couple of different occasions the family asked me if I would join them in a quick word of prayer when I came to check in on the patient. Through these moments I completely forgot that I was in the medical profession, and I became connected and a part of this family and the grieving and emotional process.

The study, published in the medical journal Academic Medicine, calls for teaching institutions to standardize team protocols to help students formally recognize and process patient deaths.

“Something akin to a spiritual ‘time out’ procedure after a patient dies might be an efficient yet effective way to acknowledge death,” researchers write.

It also calls on educators to find ways to support students in their wish to remain connected to dying patients and their families.

“Most immediately, students need support in developing habits of action conducive to their stated goals,” they write. “Encouraging students to follow dying patients who have rotated off their service, allowing students to offer their pager number and physical presence to dying patients and other like behaviors should be recognized as ’best practices’ among faculty.”


POLST Pioneer Susan Tolle: How Care Preferences May Become “For Tonight”

Posted on Wednesday, November 12th, 2014 at 11:08 pm by lifemediamatters

Dr. Susan Tolle. Cpu

Dr. Susan Tolle via youtube.com

For many seriously ill and aged Americans, advance health care directives alone will not be enough to ensure their end of life care preferences are honored in case of  emergency or incapacity, said Oregon Health and Science University medicine professor Dr. Susan Tolle during a lecture Wednesday at the University of Chicago MacLean Center for Clinical Medical Ethics.

Tolle, the director of the OHSU Center for Ethics in Health Care, began developing and disseminating the Physicians Orders For Life-Sustaining Treatment (POLST) program in 1991. POLST is a medical order that allows the terminally ill to make clear what medical treatments they desire and wish to avoid; they may indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. They may also indicate the location where they prefer to receive care.

POLST, first adopted in Oregon, is far more detailed than conventional living wills or advance directives. The form must be signed by a medical practitioner to be valid.

Tolle’s hope is that patients in their last year of life will carry a copy with them to guide emergency medical services to provide or withhold specific treatments. Ideally, a POLST form will be completed only after meaningful conversation among the patient, doctor and family.

“There has been general agreement for at least 20 years that people have a right to make decisions about the treatments they want at the end of life,” Tolle said, emphasizing that traditional advance directives are still valuable in lifting emotional burdens from family members deciding among end of life treatments for loved ones.

“It is emotionally less demanding for family members who stand by what they’ve been told to do,” Tolle added. “Advance directives also allow you to appoint a surrogate. They do some really important things.”

However, Tolle argued that advance care plans are more “philosophical and for the future.” As seriously ill individuals approach death, she said those plans should become “for tonight” in the form of a medical order.

MACLEANIncreased rates of advance directive completion have had little effect on the location of death; while only 10 percent of elderly Americans say they wish to die in a hospital, more than 40 percent do.

Tolle led a recent study of death records from 58,000 people who died of natural causes in 2010 and 2011 and determined some 30 percent had copies of their POLST form in a state-wide registry. Researchers compared the location of death on death records to POLST patient preferences, Reuters Health reports.

POLST includes three order sets that could impact the location of medical care. More than two-thirds of patients with POLST forms had chosen the first option: “prefers no transfer to hospital for life-sustaining treatments . . . transfer if comfort needs cannot be met in current location.”

In 2013, Illinois modified the Department of Public Health Uniform DNR Advance Directive to closer resemble the National POLST Paradigm standard. More than a dozen other U.S. states have similar programs.

Dr. Susan Tolle will receive the 2014 MacLean Center Prize in Clinical Ethics, an award of $50,000, during the Dorothy MacLean Fellows Conference on ethics in medicine. The conference will be held at the University of Chicago Law School on Friday and Saturday, Nov. 14th and 15th. The MacLean Center Prize is the largest award in the field of clinical medical ethics.