Diane Meier: Palliative Care Improves Quality Of Life, Reduces Medical Spending
Posted on Thursday, December 5th, 2013 at 5:21 pm by lifemediamatters
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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Duty of Physicians to Inform Patients of Hospice, Palliative Care
Posted on Saturday, June 1st, 2013 at 1:11 pm by Life Matters Media
Physicians have an ethical duty to inform their patients facing end of life about hospice and palliative care services, said Dr. Frederick Smith, director of clinical ethics at North Shore-LIJ Health System.
Smith’s presentation, part of the University of Chicago’s second annual Conference on Medicine and Religion, criticized the choices of many physicians who urge their patients to continue with more aggressive, painful treatments instead of more comfortable end of life care. Drawing inspiration from Judaism, Christianity and Islam, Smith suggested hospice and palliative care are compatible with religious teachings about death and pain. “A central function of religion is to provide meaning and consolation,” he said.
There are two things a failing patient needs to accomplish the “work of dying”: consciousness and time, Smith said. Dying allows patients time for reflection about life and opportunities for reconciliation. “Jesus wants his followers to seek reconciliation,” Smith said, noting the Lord’s Prayer.
“The Prophet Muhammad placed great value on forgiving the poor man’s debt,” Smith said. “The sacred books of the three great traditions, which originated with God’s call to Abraham, summon their adherence to a righteous life, comprised with loving adherence to God and honorable treatments to family, neighbors and even strangers. They teach that death is not the end.”
Hospice is most often used when curative treatment is no longer effective and a terminal patient is expected to live about six months or less. Palliative care is treatment that enhances comfort and improves the quality of life for patients. When deteriorating persons are not allowed time to begin the “work of dying,” they are more likely to leave feuds and conflicts unresolved, often carried on with the next generation. ”Feuds should not be taken to the grave,” Smith said.
One-third of hospice patients are too frail to begin the “work of dying,” because they are too frail, Smith said. They are transferred to hospice too late, only after aggressive treatments fail. Medicare reimburses for hospice care for up to six months, with extensions for failing patients who continue beyond six months.
Findings published in the Journal of the American Medical Association show hospice is often a last resort.
“Clinicians frequently ignore conversations about the likelihood of survival. If patients with life ending conditions truly knew the end was coming, would not it be better to take advantage of hospice?” Smith said.
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Resuscitation efforts death ritual in Western medicine
Posted on Wednesday, May 29th, 2013 at 11:19 am by Life Matters Media
Although palliative care and hospice service have improved the death experience for many Americans, demands for non-beneficial resuscitation efforts are still frequent, said neonatologist Kelly Stuart at the Second Annual Conference on Religion and Medicine in Chicago Tuesday.
Medicalizing the death experience promotes dualism, Stuart said, separating both body and soul and death ritual and medicine. She said dualism does not attend to the needs of the whole person.
Dualism is more common in the Protestant traditions, because Protestants are largely without rituals. The rituals have been lost since the Reformation and the growth of organized medicine. Rituals become funeral services, usually without prayers for the dead.
“Race has been a disparity in the marketplace, so being black is a negative indicator for advance directives,” Stuart said. Due to a long history of receiving less care than whites, many blacks opt for more aggressive treatments at the end of life.
Blacks are almost twice as likely than others to choose aggressive end of life treatments and decline do-not-resuscitate orders, according to a recent study by the American Journal of Critical Care.
“Predominately Protestant, there is also comfort in redemptive suffering for the black community,” Stuart said. Thus, many insist everything medically possible be done at the end of life- giving them they care they wanted all along. Resuscitation becomes a sort of death ritual for blacks and other Protestants, almost a Christ-like experience.
The adult children of terminally ill patients often spend months fighting with insurance companies and hospitals for their parents’ medical treatment. Once treatment begins, it can feel like giving up to elect hospice or palliative care.
Only 7.5 percent of hospice patients are black- that is less than half of their population representation in the United States, The Washington Post’s Rob Stein reported in a 2007 article.
Stuart urged reform, because aggressive treatments can lead to more painful deaths. “The American death experience lacks positive ritual, and non-beneficial resuscitation has substituted for death ritual,” she said. The medical community participates in the distortion. She urged families to remove the conversation about the subject from hospitals, and instead speak of it within the context of a family’s faith.
Stuart said she finds it helpful to speak with chaplains about suggestions for non-beneficial resuscitation. “One woman told me I wanted her son to die because he was black, it really offended me. It took me a long time to get over, but you have to come with open hands and build trust,” Stuart said.
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Unreasonable optimism among physicians common during end of life care
Posted on Monday, May 6th, 2013 at 10:06 am by Life Matters Media
Unreasonable optimism among physicians negatively impacts patients’ end of life care- often influencing the terminally ill to accept more aggressive, costly treatments with little chance of effectiveness.
Haider Javed Warraich, a resident of internal medicine at the Beth Israel Deaconess Medical Center, recounts his optimism when he first met a woman suffering from heart failure and a condition preventing blood from flowing out of her heart.
“While learning her medical history, I also got to know her,” Warraich writes. His patient was a 50 year-old former artist, derailed by addiction. “At this point, she wasn’t a suitable candidate for heart surgery. But I felt there was still hope,” he recounts in The New York Times Sunday Review.
With perseverance, Warraich convinced his colleagues to order a procedure called alcohol septal ablation. Though the procedure could potentially reduce her symptoms, it came with many risks. His patient died the next day, after a complete heart block and aggressive attempts to revive her.
Warraich explains that he was victim of “irrational optimism, a condition running rampant in both doctors and patients, particularly in end of life care.” These physicians may push for costly and more aggressive treatments as a last resort, even when there is little hope of recovery.
As a study published in 2000 for the British Medical Journal shows, about two-thirds of doctors overestimate the survival of terminally ill patients. ”Doctors are inaccurate in their prognoses for terminally ill patients and the error is systematically optimistic,” concluded the researchers, headed by Nicholas A. Christakis, then of the University of Chicago.
Many times, those poor estimates are never fully communicated to the patient. A 2001 study of cancer patients published in the Annals of Internal Medicine found that physicians only told patients their estimated survival 37 percent of the time. No estimate was given 23 percent of the time. “Around 70 percent of the discrepant estimates were overly optimistic,” Warraich notes.
A 2012 study published in the Journal of Clinical Oncology found that 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, and they have much more comfortable deaths.
“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 lead author Dr. Jennifer Mack of Harvard University Medical School.
Similarly, Warraich suggests more palliative care for patients unlikely to survive a serious illness. “Modern palliative care originated in response to the proliferation of new treatments and resuscitation technologies,” he writes. Palliative care not only provides more comfort alongside standard treatments, but it has been shown to help patients live a little longer.
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“Death denying” culture unfortunate result of medical innovation, says physician on Healthcare Decisions Day
Posted on Wednesday, April 17th, 2013 at 9:51 am by Life Matters Media
Advances in medical therapies and technological innovation have led to a “death denying” culture pervading American health care, said Dr. Susie White, an emergency medicine physician at Provena St. Joseph Hospital, during a bioethics symposium at the University of Illinois-Chicago on National Health Care Decisions Day.
National Health Care Decisions Day aims to inspire and educate the public and medical providers about the importance of advance care planning.
“Many older patients find themselves in a position they never thought they would find themselves in,” White said. “We have gained 30 years in our life expectancy.” Prior to antibiotics and modern therapies, most people died quickly- from infections, malnutrition or fevers.
Now, only 10 percent of Americans die sudden, unexpected deaths, and the sick and dying receive care in hospitals.
These shifts have fueled a “death denying” culture, one in which many wish to suppress or avoid any sign of aging or illness, White said. Families may grow angry at doctors- or even the patient- when treatments fail.
White maintains that palliative care can help patients and their families, and that the relatively recent medical specialty has the potential to reverse this culture of denial. “What we want to do is form a team of doctors, nurses, chaplains, anyone who might be helpful in an individual’s case and help anyone who has a life- limiting disease,” she said. “We want everyone in the family on the same page and smooth transitions.”
Most patients should not begin palliative care during the process of active dying, but rather, much earlier- even at the onset of illness, White said. “Palliative care is not hospice, but is an extra layer of support, that can go along with aggressive treatments,” she said.
The Integritas Institute for Ethics, a program of the John Paul II Newman Center, arranged the symposium, which explored the ethical challenges that arise at the end of life.
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