Terminally ill opt for less treatment when in communication with doctors
Posted on Tuesday, November 27th, 2012 at 1:43 pm by Life Matters Media
Cancer patients who talk with their physicians about how they want to die are less likely to opt for aggressive end of life treatments in the last two weeks of life, according to a new study published in the Journal of Clinical Oncology. Instead, these patients end life more comfortably at home or in hospice care, and as a result spend much less on hospital care.
“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said Dr. Jennifer Mack, lead author of “Associations Between End-of-Life Discussion Characteristics and Care Received Near Death: A Prospective Cohort Study.”
The researchers studied more than 1,200 patients with stage IV lung or colorectal cancer who survived at least one month from the time of diagnosis, but died during the 15-month study period. Using interviews of the patients and/or their caregivers and a comprehensive medical record review, the researchers determined if and when the patients had discussions with their doctors about end of life.
Researchers found that 88 percent had end of life discussions, but more than one-third of those took place less than a month before the patient died. Those patients who had end of life discussions documented in the medical record but did not recall them in the patient or surrogate interviews were more likely to have chemotherapy within the last 14 days of life, or acute intensive or hospital care within the last 30 days of life.
Patients who reported having the discussions with doctors were almost seven times more likely to end up in hospice than those who didn’t have those talks. Hospice focuses on comfort care and pain management for terminal patients, instead of treatment.
“A lot of patients don’t want (aggressive treatment), but they don’t recognize that they’re dying or that this is relevant for them,” said Dr. Camilla Zimmermann, head of the palliative care program at University Health Network in Toronto. She wasn’t involved in the study.
She told Reuters: “The earlier you discuss these things, the more options you have. If you wait too long, you end up having these discussions with someone you don’t know, that you just met, in an inpatient setting,” instead of with your primary doctor.
According to Mack, ”If we start these conversations early, then patients have some time to process this information, to think about what’s important to them (and) to talk with their families about that.”
In 2010, Medicare paid $55 billion for doctor and hospital bills during the last two months of patients’ lives- more than the budget for the Department of Homeland Security, according to CBS News. Twenty to 30 percent of those medical expenses may have had no meaningful impact on the patients’ health.
Reuters is reporting data from the Dartmouth Atlas of Health Care, which found that 32 percent of total Medicare spending goes to caring for sick patients in their last two years of life.
National guidelines recommend patient-physician talks begin soon after a terminal cancer diagnosis. Researchers found that physicians initiated end of life discussions an average 33 days before death.
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Emergency room nurses give advice for better care
Posted on Sunday, September 16th, 2012 at 3:08 pm by Life Matters Media
Family presence during resuscitation, more comfortable patient rooms and grieving spaces are some of the suggestions generated by a survey of 230 emergency department nurses for improving end of life care, reports a new study by the Brigham Young University College of Nursing.
More than 123 million emergency department visits are reported annually, up from 117 million in 2007. “Many patients who arrive for care to help extend their lives instead die while in the emergency department,” reports researcher Renea L. Beckstrand, Ph.D. and her colleagues.
The large number of emergency department visits only exacerbates the ongoing problem of declining access to emergency care. “High patient volume is further complicated by a decreasing number of emergency departments … the emergency department is becoming the portal for inpatient admissions, accounting for 50.2% of nonobstetric admissions nationally,” the study reports.
The study generated almost 300 suggestions for improving care.
Major themes among these suggestions include: allowing emergency department nurses to have more time to care for dying patients, allowing family to be present during resuscitation, and providing more comfortable patient rooms, privacy for dying patients, and family grief rooms. The nurses’ overall concern is for the comfort of dying patients.
Minor themes among these suggestions are: increasing social services and pastoral care, pain management and minimizing suffering, family education, and honoring patients’ desires and wishes, reports Medical Xpress.
According to the researchers: “Caring for those who are dying in emergency departments is difficult because these highly technical departments were primarily created to save lives.”
Despite the considerable obstacles to implementing these new suggestions, the study calls for incremental changes when possible from nurses and hospital staff. The study provided no future date when emergency departments would be fully adapted.
The study concludes: “Emergency nurses witness the obstacles surrounding end of life care in emergency departments, and their recommendations for improving end of life care should be implemented when possible.”
Emergency department nurses are further described in the study as “heroic” for their resourcefulness and commitment to patient care. “As in many other critical care areas of the hospitals, heroic measures often are expected in the emergency department.”
Much of the burden of emergency departments falls on nurses- from withholding life sustaining treatments to comfort care for individual patients.
The study is available at the Journal of Emergency Nursing.
Learn seven secrets of ER nurses at The New York Times.
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