Hospice and palliative care programs.

Hospice and palliative care programs have grown rapidly in the United States over the last 25 years. Relief of suffering and maximization of quality of life including symptom control, psychosocial health, and spiritual care are the primary goals of hospice and palliative care. This article reviews the development, philosophy, and practice of hospice and palliative care, and describes barriers to and suggestions for integrating this approach into mainstream medicine.

Assessment and management of pain in palliative care patients.

BACKGROUND: Pain affects more than 70% of cancer patients but is often undertreated. METHODS: The authors review and present methodologies to maximize proper palliative approaches to this symptom for the majority of patients. RESULTS: The World Health Organization's stepwise guide to pain control serves as an excellent basis for management. Around-the-clock dosing, using adjuvant treatments, and using noninvasive routes of administration provide good pain control for 80% of patients. CONCLUSIONS: Barriers to effective pain control will be reduced as new JCAHO standards regarding pain control are implemented.

Family caregiving in hospice: effects on psychological and health functioning among spousal caregivers of hospice patients with lung cancer or dementia.

INTRODUCTION: Caregiving stress has been found to lead to depression and poor health among caregivers compared with age-matched non-caregiving controls. However, most of these studies have focused on dementia caregivers, and have not included hospice caregivers. The aim of this project was to assess the impact of caregiving stress on psychological and health functioning among spousal caregivers of hospice patients, in contrast to demographically matched non-caregiving controls. A secondary aim was to compare the caregiving stressors and psychological and health functioning between spousal caregivers of hospice patients with dementia versus lung cancer. METHODS: Forty spousal caregivers of hospice patients with dementia, and 40 spousal caregivers of hospice patients with lung cancer, were compared on admission to hospice, using measures of caregiving stressors, depression, life satisfaction, and physical health, with a sample of 40 demographically equated control subjects. RESULTS: Both groups of caregivers showed higher depression, lower life satisfaction and poorer physical health (p < .05) compared with non-caregivers. Over half of all caregivers evidenced clinically significant levels of depression, with rates of depression about three times the prevalence found in community samples of older adults. CONCLUSIONS: While family caregivers of hospice patients with dementia and lung cancer face very different objective stressors, the negative psychological and health impacts on the caregiver are marked and comparable across diagnosis. Hospice family caregivers are at high risk for both psychological and physical health disorders, and caregiver depression and health problems should be systematically assessed and treated by the hospice team.

The case for hospice care in long-term care environments.

Hospice care typically is underused in long-term care facilities. Although these programs do provide other quality services, routine measurement of important parameters of end-of-life care, such as pain control, dyspnea, and spiritual and psychosocial issues, should also occur. Health care providers working in long-term care facilities should be held accountable for high-quality care for dying residents. In this environment, the benefits of hospice or hospicelike services may become immediately apparent. Continued attention to changes in the Medicare Hospice Benefits to improve patient access to hospice services and health care delivery for those living in long-term care facilities is warranted.

Physician board certification in hospice and palliative medicine.

The American Board of Hospice and Palliative Medicine (ABHPM) was formed in 1995 to establish and implement standards for certification of physicians practicing hospice and palliative medicine and, ultimately, accreditation of physician training in this discipline. The ABHPM has created a certification process that parallels other member boards of the American Board of Medical Specialties (ABMS). After 3(1/2) years and the administration of seven examinations, 623 physicians have achieved board certification in hospice and palliative medicine. Those with ABMS primary board certifications have been certified by anesthesiology, 4%; family practice, 23%; internal medicine, 55%; pediatrics, 1%; radiation oncology, 2%; and surgery, 2%. The majority describe their practice location as urban. Sixty-nine percent report more than 5 years of clinical experience in hospice/palliative medicine and 75% report an association with a hospice as medical director or hospice physician. Sixty-seven percent belong to the American Academy of Hospice and Palliative Medicine. Applicants were drawn from 48 states, Canada, and 3 foreign countries. The available data indicate only 20% were less than 40 years of age and that two-thirds were men. There is significant physician interest in seeking professional recognition of expertise in caring for terminally ill persons and their families through creation of a specialty in hospice and palliative medicine. Certification of physicians and accreditation of training programs are key elements in this process. This process will encourage more physicians to enter this field and provide needed expertise in the management of patients with progressive disease for whom the prognosis is limited, and the focus of care is quality of life.

Review of Medicare's proposed hospice eligibility criteria for select noncancer patients.

Recent events have challenged our health system to increase access to and provide high quality care for patients near the end of life. Simultaneously, Medicare is developing review policies to determine eligibility for hospice patients with select noncancer diagnoses. The purpose of this study was to determine whether the proposed policies met one of their chief goals: accurate identification of patients with a less-than-six-months prognosis. Only 35 percent of 104 patients who died within six months of admission to the hospice used for this study, LifePath Hospice, met the Medicare proposed criteria for hospice eligibility. The median and mean survival time of the sample was 14 and 30 days respectively. Based on this review, it is recommended that Medicare alter their proposed review policies and not limit access to hospice eligible patients who desire and are in need of such services.

Hospice care in the nursing home.

Hospice care is being used more frequently to provide skills and services that are not otherwise available in nursing homes. For eligible terminally ill patients, the Medicare Hospice Benefit supplies an interdisciplinary team with skills in pain management, symptom control and bereavement assistance. The Medicare Hospice Benefit also covers the cost of durable medical equipment and drugs, except for a nominal drug copayment fee. The services of the hospice team supplement the usual nursing home care at a time when staff, family members and the patient are facing the increased and urgent needs associated with the dying process. The Medicare Hospice Benefit can make it much easier for physicians and nursing home staff to provide comprehensive palliative care for terminally ill patients.

Advances in hospice care.

Hospice care developed in part as a reaction to the impersonal and technology-dependent end-of-life care offered by modern medicine. Unique approaches to care that emphasize interdisciplinary team management of troublesome symptoms and the promotion of quality of life as defined by the patient, are finding their way into all aspects of health care. Symptom control measures have expanded to include chemotherapy, radiation therapy, and multimodal therapies. Both the development of a unique knowledge base and advances in research have fostered the integration of hospice and palliative care into mainstream medicine.

Life values, resuscitation preferences, and the applicability of living wills in an older population.

OBJECTIVES: To determine whether life values are related to resuscitation preferences and living will completion in an older population and to assess beliefs about the applicability of living wills. DESIGN: Individual structured interviews. SETTING: An independent retirement community. PARTICIPANTS: One hundred thirty-two subjects older than 63 years of age. MEASUREMENTS: Resuscitation preferences were elicited in five hypothetical scenarios. Subjects with living wills were asked whether their living will would play a role in the scenarios. Subjects rated the importance of 13 life value statements. RESULTS: The percentage of subjects desiring CPR in each scenario was as follows: current condition (66%); acute illness (33%); terminal disease (8%); functional impairment (8%); and dementia (7%). The percentage of those with a living will who thought their living wills would play a role in the scenarios was as follows: acute illness (84%); terminal disease (93%); functional impairment with intact cognition (66%); and dementia (91%). Factor analysis of the life value statements revealed five meaningful factors: quality of life; capacity/autonomy; family relations; physical comfort; and treatment philosophy. Multiple correlations were found between four of five life value factors and hypothetical resuscitation preferences or the presence of a living will. CONCLUSION: Subjects misinterpreted the applicability of living wills in nonterminal illness scenarios. A relationship between life values and resuscitation preferences was noted, which emphasizes the importance of eliciting and including life values when discussing advance directives.

Care of the dying geriatric patient.

As the United State's population continues to age, there will be an increasing need to provide optimal care for terminally ill elderly patients. Physicians have a responsibility to provide care for elderly patients who are dying or in the end stages of an incurable illness. Hospice care has grown from an alternative health care movement to an accepted part of American medical care, and can be an ideal method of managing the terminally ill elderly patient. Hospice care incorporates the concept of palliative care and is designed to support the physical, psychosocial, and spiritual needs of patients at the end of life. The need for hospice care, its development, philosophies, and general principles are presented in this article.

Dementia in resuscitation policy: a prospective study of a psychogeriatric ward in a Dutch general teaching hospital.

Resuscitation decisions during the first 6 weeks were analysed for 97 admissions to a psychogeriatric ward of a general teaching hospital. Seventy-seven patients (79%) had a written 'do not resuscitate' (DNR) order on admission and 74 patients (875) had a written DNR order after 6 weeks. Morbidity was assessed with a pre-arrest morbidity (PAM) index and a modified PAM index (MPI). Dementia influenced the presence of a DNR order, both because lack of effectiveness of CPR and lack of quality of life. Age was related to a DNR order. The MPI was associated with the presence of a written DNR order, while the PAM score failed to reach significance. Six weeks after admission DNR orders were predictable by the four variables of dementia, the use of antidepressants, age and PAM, in that order. The association of the use of antidepressants with the presence of a written DNR order was surprising. The use of antidepressants is not the same as the diagnosis of depression. Because of the design, our results cannot permit any conclusion whether depression acts as an additional factor considered in decision-making in psychogeriatric patients. We suggest that depression and its correlates should be considered in discussions and studies about DNR.

Living wills and resuscitation preferences in an elderly population.

BACKGROUND: Living wills are considered clear and convincing evidence of a person's preferences for end-of-life treatment. Unfortunately, living wills often use vague language that forces physicians and others to infer specific treatment choices, like the choice to forgo cardiopulmonary resuscitation (CPR). To test the validity of such inferences we examined the relationship between living will completion and CPR preference. We also examined whether CPR choices were fixed or could be influenced by detailed information on CPR. METHODS: We interviewed 102 retired elderly persons, many of whom had living wills. We obtained CPR preferences in five hypothetical scenarios before and after providing CPR information. We then analyzed differences in desire for CPR between the group of subjects with living wills and the group without. RESULTS: In each scenario there were subjects in both groups who desired CPR. The group with living wills desired less CPR in scenarios involving functional impairment and cognitive impairment, but not in scenarios involving current health, severe illness, and terminal illness. After receiving CPR information, both groups changed their preferences such that intergroup differences were no longer seen. CONCLUSIONS: Preferences for CPR among subjects with living wills are not homogeneous, but distributed across the clinical scenarios. Therefore, one cannot infer CPR preference from the mere presence of a living will. Cardiopulmonary resuscitation information can influence preferences even among persons with living wills, implying that preferences are neither fixed nor always based on adequate information. Physicians should view vaguely worded documents as unreliable expressions of treatment preference that should not supplant informed discussion.

The lack of advance directives among hospice patients.

This study reported a lower than expected prevalence of advance directives among hospice patients. The presence of an advance directive was related to certain sociodemographic factors, diagnosis, and previous physician-patient advance directive discussions. Barriers that precluded the completion of an advance directive primarily involved a lack of physician-patient advance directive discussions or a lack of patient understanding. This study confirmed the importance of physician-patient discussion toward completion of an advance directive. Improving physician-patient communication about this issue should increase the prevalence of advance directive completion among hospice patients.

Educational objectives for medical training in the care of the terminally ill.

BACKGROUND: Palliative medicine is developing as a distinct clinical discipline worldwide. The U.S. literature describes goals for education in palliative medicine, yet this literature lacks validated educational objectives. METHOD: To develop and validate appropriate educational objectives for medical training in the care of the terminally ill, 200 randomly selected members of the Academy of Hospice Physicians were asked in 1992 to evaluate 39 educational objectives by an item-objective congruence procedure. Each objective was rated as -1 (inappropriate), 0 (unsure), or 1 (appropriate). RESULTS: Of the 200 members surveyed, 127 (64%) responded. Of the 39 objectives, 34 were considered valid, with a mean score of > or = .8. The index of content validity was .87. The objectives not considered valid all dealt with nonmedical issues related to hospice or palliative care. CONCLUSION: This study validated 34 educational objectives for medical training in the care of the terminally ill. Training programs using these objectives, amended for specific audiences, should be included in the various levels of U.S. medical education.

Prognostic factors for survival in terminal lung cancer patients.

OBJECTIVE: To determine the factors that are related to short-term survival and to develop a model that can be used to estimate prognosis in terminal lung cancer patients. DESIGN: Longitudinal cohort study of hospice lung cancer patients followed from date of admission to hospice until death. SETTING: Community-based nonprofit home hospice service. PATIENTS: Three hundred ten consecutive lung cancer patients admitted to hospice, with a separate validation sample of 78 consecutive hospice lung cancer patients. MEASUREMENTS: The relationships between survival and admission demographic characteristics, information from the history and physical examination, assessments of performance and nutrition, particular symptoms, and the presence of a living will were evaluated. RESULTS: Mean survival was 51 days, with a median survival of 27 days. Shorter survival was independently associated with those who had no living will on admission to hospice (p = 0.008), those who had tissue types other than squamous cell or adenocarcinoma (p = 0.008), those who had liver metastases (p = 0.04), those who were tachycardic (p < 0.001), those who required assistance or were dependent in their toileting (p < 0.001) and feeding (p = 0.001), those who had dry mouths (p = 0.01), and those who had severe or incapacitating pain (p < 0.05). A model estimating survival time based on the number of these significant variables present is reported (r = 0.53 in the original sample; r = 0.38 in the validation sample). CONCLUSIONS: Multiple factors, including tissue type, the presence of metastases, assessments of functional status, specific symptoms, and the presence of a living will, were related to short-term survival in terminal lung cancer patients admitted to hospice. A model utilizing these specific factors allows useful estimates of short-term survival for these patients.

The frequency of "do-not-resuscitate" order in aged in-patients: effect of patient- and non-patient-related factors.

OBJECTIVE: The purpose of this study was to examine the effect of patient- and non-patient-related factors (co-morbidity, demographics, and method of surveillance) on the frequency of "do-not-resuscitate" (DNR) orders in aged inpatients. METHODS: On a geriatric ward, during three different periods within 1 year, we used two different methods of data collection (with or without a form) and two different time-frames (prevalence or incidence) in studying the frequency of DNR orders, demographic data and the Pre-Arrest Morbidity (PAM) Index. RESULTS: In a sample of 261 patients the DNR decision was related to patient-related factors, including the PAM score and age. Only 3 patients with a score above 4 had no DNR order and in the group of 142 patients > 83 years 85 (59.9%) had a DNR order, compared to 52 (43.7%) of the 119 patients of 83 years or less (p < 0.05). In contrast, gender and marital status were not related to the presence of a DNR order. The variables PAM score, age, form and time-frame classified 76.6% of the cardiopulmonary resuscitation (CPR) decisions correctly and 71.5% of the DNR decisions correctly. Without attention to the resuscitation decision, the written DNR order frequency decreased significantly from 64-59% to 23%. An explanation for this variance may be the passive process of data collection, a non-patient-related factor. CONCLUSIONS: The DNR decision is related to the PAM index score and age. The variance in DNR decisions is partly related to the method of data collection, a non-patient-related factor in DNR decision-making. Without attention to the DNR/CPR decision, the DNR frequency decreased markedly.

Cancer-patients - the survival and expense of traditional care and hospice care.

Hospice care is a reasonable treatment strategy for those cancer patients whose disease process is no longer responsive to standard treatment regimens or who are unable to tolerate the adverse side effects of continued aggressive therapy. A 1:1 matched case-control study design that designated those patients selecting the hospice model of care as controls and those receiving acute care as cases was utilized. Data was abstracted from medical records and financial billing statements. The difference between total hospital charges plus hospice charges during the last 6 months of life for the hospice patients ($35,625) compared to the non-hospice patients ($50,152) was statistically significant. The hospice model of care may be a less costly option for those cancer patients where palliation is the objective.