The role of palliative care in the home in medical education: report from a national consensus Conference.

A working group on teaching palliative care in the home was convened at The National Consensus Conference on Medical Education for Care Near the End of Life. Our consensus statement includes: (1) a justification for education in the home; (2) general guidelines about teaching palliative care at this site; (3) identification of major barriers to training in the home, and some suggestions for overcoming these barriers; and (4) specific suggestions about how and what to teach. We find that the home is an excellent site for training in comprehensive palliative medicine. Housecalls afford an unusually rich and compelling opportunity to learn about the patient's and family's experience of severe illness and the impact of culture and environment on health care, and can have a broad humanizing effect on trainees. We propose that all medical students be familiar with this form of care. Trainees should learn the potential benefits and difficulties of managing terminal illness in the community, appreciate the role of health care teams in assuring safe, secure, high-quality care, and acquire the special knowledge, skills, and attitudes required for providing state-of-the-art palliative care for patients and families facing a terminal illness in the home, including for those dying at home. Instituting education in the home setting will require faculty development, support for more home visiting by physicians, and supervision of trainees in the home by other members of the health care team. Academic medical centers and hospice/home health agencies should collaborate to develop effective training programs.

The palliative uses of radiation therapy in surgical oncology patients.

Palliative radiation therapy has a significant role to play in the management of several clinical syndromes commonly seen by surgeons: brain and bone metastases, spinal cord compression, thoracic symptoms caused by lung cancer, bleeding, and pain or other local symptoms caused by tumor mass effects. This article discusses the basic principles of radiation therapy and radiobiology, the potential benefits, and the adverse effects and burdens of the treatment plans for each indication. This article gives the surgeon insight as to the proper time to refer patients with advanced cancer to a radiation oncologist for palliative radiation therapy.

Advance care planning.

Advance care planning is the process of planning for future medical care, particularly for the event when the patient is unable to make his or her own decisions. It should be a routine part of standard medical care and, when possible, conducted with the proxy decision maker present. It is helpful to think of the process as a stepwise approach. The steps include the appropriate introduction of the topic, structured discussions covering potential scenarios, documentation of preferences, periodic review and update of the directives, and application of the wishes when needed. The steps can be integrated flexibly into routine clinical encounters by the physician and other members of the health care team. The process fosters personal resolution for the patient, preparedness for the proxy, and effective teamwork for the professionals. The process also has pitfalls of which to be aware. Arch Fam Med. 2000;9:1181-1187

Gaps in end-of-life care.

Every year, more than 1 million Americans die of different causes. Some die easily and comfortably. Others die with a great deal of suffering and distress. This article contrasts key aspects of the way Americans die with the way they say they would like to die. It will also highlight some of the barriers to providing high-quality end-of-life care. Arch Fam Med. 2000;9:1176-1180

The patient-physician relationship. Ensuring competency in end-of-life care: communication and relational skills.

Physician competence in end-of-life care requires skill in communication, decision making, and building relationships, yet these skills were not taught to the majority of physicians during their training. This article presents a 7-step approach for physicians for structuring communication regarding care at the end of life. Physicians should prepare for discussions by confirming medical facts and establishing an appropriate environment; establish what the patient (and family) knows by using open-ended questions; determine how information is to be handled at the beginning of the patient-physician relationship; deliver the information in a sensitive but straightforward manner; respond to emotions of the patients, parents, and families; establish goals for care and treatment priorities when possible; and establish an overall plan. These 7 steps can be used in situations such as breaking bad news, setting treatment goals, advance care planning, withholding or withdrawing therapy, making decisions in sudden life-threatening illness, resolving conflict around medical futility, responding to a request for physician-assisted suicide, and guiding patients and families through the last hours of living and early stages after death. Effective application as part of core end-of-life care competencies is likely to improve patients' and families' experiences of care. It may also enhance physicians' professional fulfillment from satisfactory relationships with their patients and patients' families.

Coding and reimbursement mechanisms for physician services in hospice and palliative care.

Many physicians misperceive that the current coding system used to bill third-party payers in the United States does not include codes related to hospice and palliative care. This article will help physicians and hospice and palliative care providers to: 1) understand how to code for physician services related to hospice and palliative care; 2) review the documentation required to support such services; 3) understand the differences between the reimbursement mechanisms to be used when the patient is enrolled in the Medicare Hospice Benefit, and the usual reimbursement mechanisms; and 4) understand some of the approaches for funding non-physician palliative care services for patients not enrolled in the Medicare Hospice Benefit.

Transdermal scopolamine use in the control of narcotic-induced nausea.

Nausea affects from 40% to 70% of cancer patients who received narcotics to manage their pain. This occurs more frequently when they are ambulatory than when they are recumbent and may be the result of narcotic-enhanced labyrinthine sensitivity to motion. Scopolamine has previously been found to be an effective antiemetic for motion sickness. In a prospective pilot study, 9 (69%) of 13 cancer patients experienced rapid relief of their narcotic-induced nausea when they used Scopolamine Transderm-V patches alone. Only two patients experienced side effects with the scopolamine, and in one patient, the side effects may have been dose related. Although tolerance to the increased vestibular sensitivity may occur, this was not universal. Further prospective trials are necessary to establish whether transdermal scopolamine is useful in controlling the narcotic-induced nausea experienced by cancer patients.

A cost-minimization study of cancer patients requiring a narcotic infusion in hospital and at home.

We conducted a retrospective, non-randomized, cost-minimization study, from the perspective of the Ministry of Health, to compare the cost of managing cancer patients who required narcotic infusions, in hospital and at home. Our medical costs averaged $369.72 per inpatient day and $150.24 per outpatient day (saving $219.48 per diem, 1988 Canadian dollars), while narcotic costs were the same for any given patient in both settings. Sensitivity analysis showed that no reasonable changes in the quantity and cost of services reduced our savings by more than 50%. During incremental analysis, savings increased as more outpatient days were managed by our centre, from $0.00 for 318 days, to more than $500,000 for over 2000 days per annum. As this program has been extremely cost effective and preferred by our patients, other hospitals and central funding agencies might consider establishing a regional outpatient narcotic infusion program to reduce their costs.

Inpatient narcotic infusions for patients with cancer pain.

Morphine and hydromorphone infusions of 6 or more (average 25.75) days in duration were used with increasing frequency (up to 7%) by our oncology inpatients. Eighty-six percent of the 135 inpatients we reviewed realized good pain control with dose rates up to 700 morphine-equivalent (ME) mg/h. Local toxicity occurred on only 10 occasions. Systemic side effects secondary to the infusion were reported 75 times and were generally readily reversed. Myoclonus was seen in 11% of our patients at dose rates as low as 60-90 ME mg/h. Adjuvant therapies were not used as frequently as might be warranted. We believe that narcotic infusions, particularly subcutaneous ones, are safe and effective. Further prospective trials are needed to clarify how they should be combined with other therapies to control cancer pain that is poorly responsive to narcotics, and to better understand the etiology and management of serious side effects.