Download What the Media Said about End-of-Life Care This Week

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HOSPICE NEWS NETWORK
What the Media Said about End-of-Life Care This Week
Volume 15, Number 8
March 1, 2011
A Service of State Hospice Organizations
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CMS RELEASES TOOLKIT FOR HOSPICES
CMS recently announced the release of its Hospice Assessment Intervention and
Measurement (AIM) Project toolkit. The online service “provides a self-evaluation tool, a
retrospective data collection tool, a data dictionary, staff education materials, and
supporting documents that will help hospices comply with the current Quality Assessment
and Performance Improvement (QAPI) regulatory requirements, improve the care
provided to patients, and start getting ready for systematic data collection and quality
reporting.”
The toolkit, available at the IPRO link below, was developed under a CMS contract
with the Carolinas Center for Medical Excellence PEACE (Prepare, Embrace, Attend,
Communicate, Empower) Project. The measures from the PEACE project were tested in seven
hospices, and, to a limited extent, in a hospital with a palliative care service. The toolkit
“contains the measures that were considered usable, feasible, and reliable during the testing
process.”
The toolkit has six sections, each of which includes subheadings. Each of the
subheadings has relevant supporting materials and tools. Additional resources, such as
websites, journals, books, etc. are listed at the end of each major section. There is also a
references section that has a more complete bibliography. The sections are as follows:
* Preparation: Hospices should engage in several activities so that the AIM quality
measures can be effectively used. These include organizing a quality team, preparing the
organization for change, self-assessing the organization, reviewing the agency’s documentation
processes, using standardized rating scales, and introducing the AIM process to the staff.
* AIM Data Collection: Activities in this section include selection of a data abstraction
team, training the team, selecting the clinical records, capturing the data, and assessing
reliability. Two Excel spreadsheets are included to assist in data abstraction and entry.
* Calculate Quality Measures (assign quantities to attributes of care that can drive your
quality improvement process): This section teaches providers how to know whether their data is
correct and how to correct it if it is not, how to interpret the data, and detailed information on the
technical specifications and data algorithms for each of the measures.
* Changing Your Practice: Discussions in this section include processes for assessing
quality and improving performance, performance improvement projects and interventions,
cultural diversity, and additional resources. (CMS, 1/26, www.cms.gov/center/hospice.asp;
IPRO, www.ipro.org/index/hospice-aim)
SCREENING FOR DELIRIUM AND DEPRESSION IN HOSPICE
INPATIENTS
“Ease of Screening for Depression and Delirium in Patients Enrolled in Inpatient
Hospice Care,” in the Journal of Palliative Medicine,” says, “Major depression and delirium
are prevalent, underrecognized, and undertreated in hospice and palliative care settings.
Furthermore, they are both associated with significant morbidity and mortality.”
In a California hospital, hospice inpatients were screened for depression by social
workers on admission, and daily for delirium by the nursing staff. In using a simple two
question assessment, seventy percent of patients screened positive for depression on
admission. Sixty-four percent screened positive for delirium at least once during their
inpatient stay. Hospice staff considered both screenings to be relatively easy.
The article says that depression can “interfere with a patient’s capacity to make
decisions, understand his or her situation, interact with caregivers, … reach final goals,
[and] severely impact physical health and quality of life.” Delirium “may result in
unnecessary medical intervention, distress to family and caregivers, and/or inpatient
hospice admission, … [and] interfere significantly with the recognition and control of other
physical and psychological symptoms, such as pain.”
The study concluded. “There were no significant associations between a positive
screen of depression or delirium and patient gender, age, ethnicity, terminal diagnosis, or
marital status.” The authors further add that the results support the observation that both
“depression and delirium are very common in hospice inpatients.” They also note that the
purpose of the study was to evaluate the ease of use and accuracy of the screening tools, and that
the results need to be confirmed in larger studies. (Journal of Palliative Medicine, 2011,14(3),
www.liebertonline.com/doi/pdfplus/10.1089/jpm.2010.0179)
RESEARCH & RESOURCE NOTES
* JAMA has two articles dealing with patients with cognitive deficits and their
finances. “Finances in the Older Patient with Cognitive Impairment” says, “Clearly
delineating the clinician's role regarding identification of financial impairment could establish for
patients and families effective financial protections and limit the economic, psychological, and
legal hardships of financial incapacity on patients with dementia and their families.” The author
of “Damage Prevention and Control for Financial Incapacity” says, “In an aging society, all
professionals serving older adults have an obligation to understand diminished decisional
capacity, especially with respect to financial issues, and to acquire the basic skills to identify it
and respond constructively to it. Failure to meet the challenge will only increase the potential for
financial abuse and exploitation.” (JAMA, 2011,305(7):698-706,
dx.doi.org/10.1001/jama.2011.164; JAMA, 2011,305(7):707-708,
dx.doi.org/10.1001/jama.2011.187)
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* An article in the Journal of Palliative Medicine says that dexmedetomidine
(Precedex) can produce sedation and analgesia without respiratory depression. The article
describes the use of the medication in a patient with advanced cancer who had not gotten
relief with other treatments. (Journal of Palliative Medicine,
2011,14(3),www.liebertonline.com/doi/pdfplus/10.1089/jpm.2010.0235)
* The American Society for Radiation Oncology’s Clinical Affairs and Quality
Committee has developed a guideline for use of radiation therapy for metastatic bone
cancers. The press release says that external beam radiation therapy (EBRT) “provides
successful pain relief in 50 to 80 percent of patients with little risk of side effects,” but that the
guideline is needed to standardize care. The guideline, which will be published in the
International Journal of Radiation Oncology/Biology/Physicis, can be obtained now by
emailing [email protected]. (ASTRO News, 2/17,
cs.astro.org/blogs/astronews/pages/press-release-astro-publishes-palliative-radiotherapy-forbone-metastases-guideline.aspx)
* A study using data from The Dartmouth Atlas of Health Care, the Health and
Retirement Study and Medicare claims examines the factors that contribute to Medicare
expenditures at the end of life, while “accounting for regional characteristics.” Higher
expenditures were associated with decline in function, Hispanic ethnicity, black race, and certain
chronic diseases. Regional characteristics such as end-of-life practice patterns and hospital beds
per capita were also associated with higher expenditures. The abstract concludes, “Patient
characteristics, such as functional decline, race or ethnicity, chronic disease, and nearby
family, are important determinants of expenditures at the end of life, independent of
regional characteristics.” (Annals of Internal Medicine, 2011,154(4):235-242,
www.annals.org/content/154/4/235.abstract)
* The Mid-Atlantic Renal Coalition has announced the development of the
Coordination of Hospice and Palliative Care in ESRD (End-Stage Renal Disease)
educational module. The module, developed by the Kidney End-of-Life Coalition and the
American Nephrology Nurses’ Association (ANNA), addresses “misconceptions about hospice
requirements, challenge common barriers of care and identify the need to provide end-of-life
services for kidney patients.” The module is free at the Kidney End-of-Life Coalition and
ANNA websites, which are linked at the URL below. (Nephronline, 2/17,
www.nephronline.com/news.asp?N_ID=4442)
* A study of Medicare beneficiaries with heart failure between 2000 and 2007 looked
at the use of resources in the last six months of life. The abstract says, “Among Medicare
beneficiaries with heart failure, health care resource use at the end of life increased over
time with higher rates of intensive care and higher costs. However, the use of hospice
services also increased markedly, representing a shift in patterns of care at the end of life.”
(Archives of Internal Medicine, 2011,171(3):196-203,
dx.doi.org/10.1001/archinternmed.2010.371)
* A study of ER residents in New York City asked them to answer questions about
palliative care in the ER, their level of formal training and comfort in managing symptoms
and discussing end-of-life issues, and indicate their level of interest in future palliative care
training. Half had some palliative care training before their residency, but fewer than one-fourth
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had a “clear idea of the role of palliative care” in emergency medicine. The residents reported
higher levels of formal training in advanced directives and end-of-life legal issues than in end-oflife symptom management. They had higher levels of self-reported comfort in giving bad news
than in withholding or withdrawing therapy. Most favored additional palliative care training.
(Journal of Palliative Medicine, 2011,14(XXX),
www.liebertonline.com/doi/pdfplus/10.1089/jpm.2010.0343)
* “Adverse Events in Hospice and Palliative Care: A Pilot Study to Determine
Feasibility of Collection and Baseline Rates” examines adverse events in a palliative care
inpatient service that were symptomatic of the patients’ illnesses: “falls, confusion,
decreased consciousness, hypo- and hyperglycaemia, urinary retention, and hypotension.”
Seventy-eight percent of patients had incidents which precipitated their admissions, and 62% of
those had at least one other event during their stay. Only 4 patients had no adverse events. The
authors conclude, “This pilot highlights the feasibility of collecting, and ubiquity of,
symptomatic adverse events, and forms a baseline against which future interventions to
decrease the frequency or intensity can be measured. Given the frailty of hospice and
palliative patients, any adverse event is likely to accelerate irreversibly their systemic
decline.” (Journal of Palliative Medicine, 2011,14(3),
www.liebertonline.com/doi/pdfplus/10.1089/jpm.2010.0392)
HOSPICE, PALLIATIVE CARE & END-OF-LIFE NOTES
* “How to Ensure Your Last Wishes Are Carried Out,” in US News & World Report,
emphasizes that the most important document you can have is a healthcare power of
attorney, which is called a healthcare proxy in some states. Not all elder care attorneys
favored having living wills, and some also recommended having a financial power of
attorney. The attorneys strongly urged people to make their wishes widely known. One
said, “It does no good to do these legal documents if you then hide them in a safety deposit box
or put them on a shelf. By telling your loved ones your feeling on the subject, you are more
likely to get the kind of medical treatment you would prefer if you were making the decision.”
(US News & World Report, 2/25, money.usnews.com/money/blogs/the-bestlife/2011/02/25/how-to-ensure-your-last-wishes-are-carried-out)
* In Lubbock, Covenant Medical System recently dedicated its new palliative
medicine unit. Its palliative medicine program began in 2005, but now has its own place in the
hospital. The new unit “includes state-of-the-art equipment, 14 private rooms and
accommodations for families to stay with patients. The area also includes a meditation or prayer
room, a family gathering room and a children’s play area. The palliative unit will also host pet
therapy.” (Lubbock Avalanche-Journal, 2/15, lubbockonline.com/health/2011-02-15/covenantunveils-palliative-medicine-unit)
* The shortage of prescription drugs that was supposed to get better in 2011 has
gotten worse, Vanderbilt Medical Center pharmacist Michael O’Neal says. “Five years
ago, there were 30 drug shortages. Today there are 150,” according to O’Neal. The FDA is
holding pharmaceutical companies to higher standards and, in their trying to follow the
standards, they have slowed production down. The shorted drugs include sedatives, pain
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medications, and therapy drugs for cancer treatments. (WSMV-TV, 2/22,
www.wsmv.com/health/26946998/detail.html)
* An article in the Wichita Falls Times Record News features Oreo, the “top dog” of
Hospice of Wichita Falls. Oreo, who definitely knows “where to go for treats,” follows the
nurses around, attends staff meetings, and naps with the patients. Oreo started coming to
the center when one inpatient, who had lived alone with his little dog, missed his pet. Dr.
Barbara Murphy owns Oreo, and she brought her in to keep the patient company. The Hospice
encourages visits by patients’ pets, and encourages those would like to bring certified therapy
animals to the hospice to contact them at 940-691-0982. (The Times Record News, 2/26,
www.timesrecordnews.com/news/2011/feb/23/mans-best-friend-until-the-end/)
* An article in USA Today explains palliative care. While 80% of large hospitals
offer palliative care, most cancer patients get much of their care outside of hospitals, where
palliative care is harder to find. The article emphasizes that hospice is a form of palliative
care for the last months of life, but that palliative care should be discussed and can be
started at the diagnosis of an illness that will require it. Citing Thomas Smith, of Virginia
Commonwealth University’s Massey Cancer Center, the author says that usually “the cost
savings from palliative care are spread throughout the system — saving money for Medicare, for
example — instead of returning money to individual hospitals or programs. … So in the short
term, individual hospitals may lose money, even if the country overall saves money.” (USA
Today, 2/22, yourlife.usatoday.com/health/medical/treatments/story/2011/02/Palliative-careprolongs-life-reduces-suffering/44046292/1)
* Grieving a Soulmate: The Love Story Behind “Till Death Do Us Part” was written by
Robert Orfali after the death of his wife from ovarian cancer. The reviewer says that
Orfali tackles the issue of grief “with courage, out-of-the box thinking, and deep love. …
The content is thought-provoking, unique and original. It’s your gentle and informed guide to
the deep grieving that accompanies the death of a soulmate. … It also tells you how to
reconstruct your life, find meaning, and deal with the big existential issues from a secular
perspective.” (San Francisco Bay Area Today, 2/24, sanfranciscobayareatoday.org/new-griefcounseling-guide-%E2%80%9Cgrieving-a-soulmate%E2%80%9D-book-announced/11228/)
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Ask your insurance agent to visit their website at www.hccis.com.
Hospice News Network is published 45-47 times a year by a consortium of state hospice organizations. Copyright, 2011. All rights reserved to
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information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources.
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