The role of the physician in hospice.

As the concept of hospice has evolved in the United States, it has become apparent that there is a significant need for increased physician participation in all aspects of the care of terminally ill patients provided by hospice programs. Four distinct physician roles have emerged: the attending physician, the consulting physician, the hospice medical director, and the hospice team physician. As the roles of the hospice medical director and team physician have become better defined, many physicians are finding that palliative medicine and full time hospice employment is a rewarding career option. The increased involvement of physicians in all aspects of hospice and palliative care will result in measurable improvement in the quality of patient care that hospice programs provide to terminally ill patients and families.

Debility, unspecified: a terminal diagnosis.

OBJECTIVE: To determine whether the diagnosis "debility, unspecified" (ICD-9 code 799.3) is appropriate for use with terminally ill patients and to define the criteria for assigning the diagnosis. DESIGN: A survey of patient charts to determine the clinical characteristics of a defined cohort. SETTING: A comprehensive hospice program with average daily census over 500 patients. PATIENTS: All patients who died in the hospice program during the period from January through October, 1993 and were assigned a diagnosis of "debility, unspecified" (ICD-9, 799.3). MEASUREMENTS: For each patient, the following information was recorded: demographics, level of function (ability to carry out activities of daily living), presence of major system disease, other illnesses, any other appropriate ICD-9 coded diagnosis. RESULTS: The diagnosis of "debility, unspecified" was confirmed in 50 out of 53 cases. All 50 patients exhibited multiple comorbid conditions. Major organ system impairment included central nervous system (96 percent of patients), cardiopulmonary (76 percent of patients), skin integrity (42 percent of patients), and sepsis at the time of admission (30 percent of patients). The average survival for these patients was 67 days and the median survival was 20 days. In none of the 50 patients was there a single major system impairment of a degree to warrant a specific terminal diagnosis. CONCLUSIONS: The use of the ICD-9 code 799.3 "debility, unspecified" as a terminal diagnosis was confirmed to be appropriate based on survival and hospice length of stay data and on the fact that no patients exhibited a singular major system disease sufficient to support a terminal prognosis. A decision tree for assigning the diagnosis is presented.

Ethical dilemmas in hospice and palliative care.

In order to understand some of the ethical dilemmas that face hospice programs in the United States, one must understand the Medicare Hospice Benefit, which is the model by which hospice programs provide palliative care to terminally ill patients in the United States. Unlike palliative care programs outside the United States, patients must have a prognosis of 6 months or less to receive hospice care under the Medicare Hospice Benefit. Care is reimbursed on a per diem basis, and inpatient care is restricted to pain and symptom management that cannot be managed in another setting. Ethical dilemmas that face physicians referring patients to hospice programs include the ability of clinicians to predict accurately a patient prognosis of 6 months or less, and to what extent hospice programs and clinicians are obligated to provide patients with full information about their illness, as the Medicare Hospice Benefit requires that patients sign an informed consent in order to elect the hospice benefit. There are ethical dilemmas that affect day-to-day patient management in palliative care programs including physician concern over the use of morphine because of possible respiratory depression in the advanced cancer patient, the question of providing enteral or parenteral nutritional support to patients who refuse to eat near the end of life, and the question of providing parenteral fluids to patients who are unable to take fluids during the terminal phases of illness. A final ethical dilemma concerns the methodology for quality of life research in palliative care. By following current research dogma, and only considering patient-generated data as valid, the patient population that most needs to be studied is excluded. A new methodology specifically for palliative care research is needed to provide information on the patients who are cognitively or physically impaired and unable to provide input regarding their needs near the end of life.

Severity index scores correlate with survival of AIDS patients.

A major concern of hospices treating AIDS patients is survival prognosis. Patients are eligible for government hospice benefits only if they are in the last six months of life, but for AIDS patients who present at different disease stages, it is often difficult to predict survival. We have tested an index of AIDS severity developed by Alemi et al. (1991, Interfaces, 21(3), 105) for its ability to predict survival in hospice-AIDS patients. Using retrospective analysis of medical records, a severity index (SI) score was determined for 26 AIDS patients who were admitted at different disease stages to a South Florida hospice. The length of stay for each patient was also recorded. The patients fell clearly into two groups, those with stays of six months or less and those with stays of more than six months. The mean SI scores of the two groups were .9188 and .7845, respectively. These scores were significantly different at the p = .005 level. In this preliminary study, the severity score correlated well with survival prognosis. Based on these results, it appears that the severity index may have great utility in predicting survival for AIDS patients seeking hospice admission.

Remission of rapidly growing desmoid tumors after tamoxifen therapy.

A patient is described with Gardner's syndrome manifested initially by an extra-abdominal desmoid which was resected. The case was complicated by metastatic adenocarcinoma of the colon and recurrence of several large painful desmoid lesions. In view of the predilection of desmoids to occur in women in their childbearing years, it was decided to treat these painful lesions with an anti-estrogen, tamoxifen (20 mg orally, four times daily). This therapy led to a complete relief of pain within 1 week and a progressive decrease in the size of the desmoid tumors to less than 50% of their initial volume by the end of the second week. Unfortunately, the patient's metastatic adenocarcinoma progressed and was complicated by sepsis leading to her death. This case suggests that the growth of desmoid tumors is under hormonal influence, a suggestion which deserves further investigation.