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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 ___________________________________________________________________________ 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) 2 * 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 3 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 4 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/) Glatfelter Insurance Group is the national sponsor of Hospice News Network for 2011. Glatfelter Insurance Group provides property and liability insurance for hospices and home healthcare agencies through their Hospice and Community Care Insurance Services division. 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 HNN subscribers, who may distribute HNN, in whole or part, to provider members of the subscribers’ state organizations. If readers need further information, they should consult the original source or call their state association office. HNN exists to provide summaries of local, state and national news coverage of issues that are of interest to hospice leaders. HNN disclaims all liability for validity of the information. The information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources. The information in HNN is not exhaustive and HNN makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the information. HNN does not and cannot research the communications and materials shared and is not responsible for the content. If any reader feels that the original source is not accurate, HNN welcomes letters to the editor that may be shared with HNN readers. The views and opinions expressed by HNN articles and notes are not intended to and do not necessarily reflect views and opinions of HNN, the editor, or contributors. Only subscribing state hospice organizations have rights to distribute HNN and all subscribers understand and agree to the terms stated here. 5