More, Better Hospice Care.

Patrice Villars writes at GeriPal on the ways to improve care for patients in hospice care: make treatments more individualized:

Registered nurses are trained to alleviate suffering through diagnosis and treatment of human responses to actual or potential illness. We are trained to assess and treat based on holistic goals and to view the patient in the context of their defined family. Palliative care and nursing philosophy share a holistic approach to care that encompasses physical, emotional and spiritual concerns of the patient and family unit. It is no small wonder that nurses have been the foundation of community hospice work since its beginnings. Physicians are trained to formulate and treat medical diagnoses. Nurse Practitioners are, well, the middle children. We are nurses who have advanced training in diagnosis and treatment of medical conditions in addition to our foundational training. Our medical training is not as deep or broad as that of physicians. Nurse practitioners often pursue further training to develop an area of expertise.

None of us truly knows what we don’t know. Even the most experienced hospice nurses don’t know how their practice would differ if they had the advanced education and training of a nurse practitioner. Few physicians or physician assistants understand the level of training of RNs or LVNs/LPNs, nor their scope of practice. How could they? They’re not nurses. Only the nurse practitioner holds the dual training and, as such, is the perfect liaison for optimal collaboration between these two disciplines.

Surprisingly, nurse practitioners do not play a pivotal role in most community hospice agencies. Medicare requires that there be a physician medical director. Registered nurses usually function as the hospice case manager for the care of the end stage illness.

Hospice nurses are well trained in using medications to manage symptoms. Hence the array of the (all too often) ‘one size fits all’ order set of PRNs. This makes sense when the nurse is out in the home or on the phone doing her/his very best to assess and treat distressing symptoms at the end of life. It’s pretty difficult to track down the doctor of record, contact her/him, describe the situation, request an order and get it to the patient within a reasonable period of time such that the patient (and family) does not suffer for hours longer. Having pre-signed orders to use PRN can be a life-saver (no pun intended) at times. The downfall is the one size fits all practice. Shortness of breath equals morphine; anxiety equals lorazepam; confusion/agitation equals haldol.

There is continued grumbling among hospices and palliative care folks that patients are often referred too late to hospice care. However, at least in the case of patients with some non-cancer diagnoses, are they? Is our system set up to care for these patients optimally at the end of life? Sadly, I think not.
Happily, there is a relatively easy solution – use nurse practitioners who have advanced training in palliative care and (my bias) gerontology.
What if hospice nurses had easy access to a palliative care NP who had the training to assess and treat medically complex patients at the end of life? What if the hospice nurses had access to someone who understood their practice and could provide the appropriate education and support to improve their practice? What if the NP was available for home visits? Hospice nurses might practice differently. Patients would get better care. And health care providers might not be so reticent to refer their patients a little earlier.

Health Care Reform and Palliative Care.

Tim Cousounis at Palliative Care Success looks at the reasons why Palliative care, though cost saving and vital to good end of life care, is not likely to expand at a great rate any time soon:

Why are we not likely to see the influence of palliative care advanced during the health reform period? Two reasons leap to mind.
One, hospitals and hospices are the most prominent, and frequent, sponsors of palliative care programs, and we know what’s happening to their reimbursement (it's getting squeezed, with no end in sight). So, as these provider organizations are forced to tighten their belts, is it reasonable to expect (especially in light of the heightened priority on patient safety ) hospitals to increase their financial support of palliative care services? Furthermore, it’s unlikely that the financial performance of hospices will dramatically improve anytime soon. So, we shouldn’t expect a legion of hospices across the nation committing greater resources to palliative care services. It’s not that hospital and hospice executives are tone-deaf to palliative care. It’s just that these executives are faced with budgetary trade-offs and palliative care is not (yet) a high priority.
Two, primary care continues to be undervalued within the American medical system. Will these prevailing views change? Of course. Anytime soon? Unlikely. American primary care is in shambles, and it is now clear that it will not be viable in the future unless significant changes occur in our national attitude about its value and in the way we pay for it. While in other developed nations, 70-80 percent of all physicians are generalists and 20-30 percent are specialists, in America the ratio is reversed, the result of a payment system that has evolved to reward expensive care and penalize proactive management, even though the data are unequivocal that more palliative care (according to the Dartmouth Medical Atlas) within a community results in lower costs and better late-life care.

Opioid Use for Elder, Chronic Pain Relief.

Don't miss the fantastic discussions at Pallimed and GeriPal regarding the use of opioids for relief of pain in the elderly. Last week's study is dissected by the amazing commenters and you'll have a better understanding of the challenges faced when working to relieve pain.

Here's a clip from GeriPal's article to bring you up to speed:

As noted on the Pallimed blog, a study published last week in Annals of Internal Medicine reports on adverse events associated with the prescription of opiates for chronic non-cancer pain.

In brief: they studied 9940 HMO patients (mean age 54) who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005. They used ICD codes with subsesquent chart review to identify "opioid-related overdoses", and found 51 events, of which 6 were fatal. After stratifying by categories of opiate exposure, they estimated that annual overdose rates were 0.2%, 0.7%, and 1.8% among patients receiving less than 20 mg, 50 to 99 mg, and more than 100 mg of opioids per day, respectively. (For more journal-club style details and analysis, check out the Pallimed post, which is good reading for those with a little more time and interest.)

I'll confess that when this article caught my eye, one of my first thoughts was "Argh! Now it will be even HARDER for me to persuade my elderly patients to try a little low-dose opiate for their severe arthritis, when all else has failed to control their pain."

Yes, it's true. I have some of my arthritic elders taking a little daily opiate for their pain: it allows them to walk around a little more and maintain their function, or so I tell myself.

But what do the rest of you think? In particular I'm curious to know what the primary care clinicians among you prefer to use for chronic noncancer pain in frail elders. And how easy do you find it to address the patient's (or often, the family's) worries about the risk of addiction or overdose? Will this latest study change your practice?

And here's the link to Pallimed. Don't miss the comments at either section.

The Need for Geriatrics.

From GeriPal, a response to a recent op-ed by Dr. Lewis Lipsitz in the Boston Globe:

One of the nice things that were articulated in this op-ed is that one of the most of the important roles of the Geriatrician is to listen. While many older patients have a whole bunch of specialists, it is the role of the Geriatrician to put everything together, listening to the patient and caregiver at great length. There was one rather stunning statistic in the op-ed. In 2007 only 91 new Geriatricians were trainied in the US. As the need for Geriatrics is increasing, the number seeking training is falling.

Dr. Lipsitz notes a major problem recruiting Geriatricians is the poor compensation compared to other medical specialties. The key skills taught in Geriatrics are not lucrative procedural skills---and spending more time with patients is certainly not profitable.

snip

Dr. Chris Langston, program director at the John A. Hartford Foundation, has an excellent discussion of this article on the health AGEnda blog. He calls on all of us to step up to the plate and make the case to the public for better care for older patients, and the workforce issues that are needed to make this happen.

GeriPal: Bowel Med Taste Tests and More!

Where can you find rants about medical euphemisms, bowel medication taste tests (don't miss the video!) and some frank, knowing Big Pharma talk? At my new favorite site: GeriPal.org! Your source for Geriatrics & Palliative Care News and Collaboration.

Great articles you don't want to miss:

A September post recaps a study of the dangers of bedrest during hospitalization:

It is well known that hospitalization is a very vulnerable period for older persons. Many elders who are hospitalized for seemingly routine illnesses leave the hospital with a major new disabilty that threatens their ability to live independently. This happens even though the medical problem that resulted in hospitalization is resolved. Most studies suggest that about 1/3 of medical hospitalizations in persons over the age of 70 will result in a major new disability---this risk is over 50% in patients over age 85. Many Geriatricians believe that the type of care provided in the hospital contributes to the development of disability. A chief concern is bedrest. Older people seem to weaken quickly when confined to bed, and a number of studies show rapid loss of muscle mass in elders confined to bed

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From today, a summary of the new New England Journal of Medicine article on end stage Demential and palliative care:

Hopefully, recognizing that end stage dementia is a terminal condition will result in improved care---care focused on the quality of life of patients and the needs of their families. Mitchell's findings suggest that communication with families is often poor---It is likely that many families would choose to avoid burdensome hospitalizations and "treatments" such as tube feeding if they understood the burdens and marginal potential for benefit. Even when such therapies are continued, palliative care should generally be offered simultaneously. The difficulty estimating prognosis has often prevented hospice referral in patients with dementia. This study helps by showing that pneumonia seems to signal an average 6 month survival in advanced dementia.

The site is a wealth of information on pain and symptom treatment, new study summaries, and general industry commentary that can keep even a medical layman like me engaged. They also offer email alerts!

As I delve deeper into the issues of aid in dying, end of life care, palliative medicine, and hospice care, I find accessible studies and engaging commentary to be, well, not the standard. Some day soon I should do a tab dump of all my favorite sites, but in the meanwhile, enjoy this one.