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Emphasize Quality of Care in Hospice and Palliative Care

Posted 1/10/2013 Categories: palliative care, patient goals of care, hospice

In his New York Times opinion piece about end-of-life care, Better, if Not Cheaper, Care, Ezekiel Emanuel makes some perfectly valid points. Yes, hospice care is usually better able to meet the needs of patients in the last months of life than hospitals. Yes, patients deserve hospice care at home even if the health care system is unable to save money doing so. Yes, reliable evidence that hospice care costs less than traditional care remains hard to come by and, where it exists, is inconsistent and thus inconclusive. And yes, among the overriding reasons the cost of end-of-life care may be so high is, as he suspects, that patients are often transferred to hospice at home too late.

But in addition to addressing the costs of end-of-life care, we’d like to put the emphasis on the right care at the end-of-life for our nation’s citizens. The quality of the care given during a patient's final weeks and months should be respectful, palliative and holistic. In our view, those care qualities are at the heart of hospice.

The premise that hospice care saves no money for the health care system in the long run strikes us as debatable. In the best of scenarios, it does. On this much we can certainly agree: let's all take a harder, peer-reviewed look at the dollar figures involved in end-of-life care than we have to date. But let's make sure quality is always part of the equation.

If our experience at Amedisys in providing hospice and palliative care to more than 25,000 patients across the United States has taught us anything, it's that patients expect and deserve an end-of-life experience based not on economics but, rather – and above all – on clinical skill in meeting the patient’s goals of care and the deepest possible compassion.

About the Authors

Michael Fleming, MD, FAAFP is the chief medical officer for Amedisys, and Past President of the American Academy of Family Physicians and the Louisiana Academy of Family Physicians.

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

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Having Your Own Say: Getting the Right Care When It Matters Most

Posted 6/19/2012 Categories: home health, palliative care, patient goals of care, hospice, chronic care

Guest post by Dr. Bernard Hammes, director of the Gundersen Health System’s Respecting Choices and Medical Humanities Program

There is a movement afoot. We are transforming from an impulsive attempt to “cure at all costs” to one that is patient and family centered and focuses on informed choices and quality of life for those with advanced illness.

Patient and family-centered care for those with advanced illnesses are a necessity – our humanity and nation depend upon it.

Why force patients into weeks and sometimes months of acute-care hospitalizations when what they want is pain relief, symptom management and their loved ones around them – in the comfort of their own home?

Why continue with a “cure at all costs” philosophy, when respecting informed, patient treatment wishes ensures higher quality care and may save $25 billion in annual health-care costs for the nation’s health system?

These are the questions we explore in our book, Having Your Own Say… Working with some of the most prominent medical professionals in the U.S. and Australia, we explore innovative and proven models for patient centric end-of-life healthcare options.

Our goal in highlighting the various healthcare models in this book is to ensure that patients receive the treatment they desire for themselves based on truly informed decisions to avoid both over - or under - treatment. To me, it’s about giving patients the quality of end-of-life care as defined by each individual and, for their families, it’s about making sure their loved ones’ wishes are known and followed.

One colleague, Dr. Michael Fleming, chief medical officer for Amedisys, is another passionate advocate for patient-centered care. That’s why I asked him to author one of the chapters for Having Your Own Say…In chapter 10, he wrote about “Focusing on the Patient’s Needs and Desires: Care at Home.” He cited an AARP poll that tells us 89% of individuals age 50 years and older want to remain in their homes as they age, including receiving treatment there.

Health care at home allows clinicians to identify in-home safety hazards, medication discrepancies, and social challenges not always visible in a clinical setting. So, home is not only where people want to be, but the comforts of home have also been proven to promote healing, reduce health risks, and is more cost-effective to other post-acute care settings.

Dr. Fleming and I both adhere to the Institute of Medicine’s philosophy that all care should, “deliver the right care, for the right person, at the right time.” In order to achieve this goal, we must evolve.

Can we (the legacy health system) evolve to a patient-centered care model?

Will people with advanced illness become empowered and informed decision-makers regarding their care before it’s too late?

We’d love to hear your thoughts. Please email us with your comments to RespectingChoices@gundluth.org.

And may all of us have the support, courage and knowledge to see death as “…a continuation of life, and a friend to be prepared for,” as Joseph Cardinal Bernadin wrote in his memoir about facing death during his battle with cancer.

For more information about the book: http://www.havingyourownsay.org/

Dr. Bernard Hammes is the director of Medical Humanities and Respecting Choices® for Gundersen Health System headquartered in La Crosse, Wis. In this position, he provides educational programs for house staff, medical students, nursing students and physician assistant students. Dr. Hammes’ work has been primarily focused on improving care for patients with serious illness. He has developed institutional policies and practices, staff education and patient/community education with a special focus on advance care planning. This work has resulted in two nationally recognized programs on advance care planning: If I Only Knew... and Respecting Choices. He served as editor for the book Having Your Own Say: Getting the Right Care When It Matters Most.

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6 Steps for Discussing Goals of Care and Sharing Bad News

Posted 4/13/2012 Categories: home health, palliative care, patient goals of care, hospice, chronic care

The Burden of Illness and Goals of Care

It is no secret that Americans are living longer than ever. In fact the number of seniors has grown by a factor of 11 over the last century. By 2030, 1 in 5 Americans will be over 65. Unfortunately longer life is often accompanied by chronic illness. Thirty-percent of seniors have three or more chronic diseases, 80% of people over 80 have difficulty performing some activities of daily living. More and more Americans and their families must cope with the burden of chronic illness for months to years before death.

When facing the final years of life with its accompanying burden of illness, symptoms and functional decline most people begin to change their health care goals. Some patients are interested in rehabilitation and recovering strength. Others focus on avoiding hospitalizations so they can live at home with family members. Still others decide to avoid burdensome efforts aimed at prolonging life and want aggressive symptom management and care oriented toward comfort.

Unfortunately many research studies show that physicians and other healthcare providers typically avoid discussing goals of care and prognoses with patients. Often it is because these conversations are difficult and involve sharing bad news. However, for patients in the last few years of life to receive the care they want that is consistent with their values and wishes, health care providers must be skilled at challenging conversations. In short, they must be expert communicators.

Many clinicians mistakenly believe that experience alone is sufficient to prepare them for discussing goals of care and sharing bad news. It is also easy to assume that simply lending a sympathetic ear or having compassion for seriously ill patients equips them with the ability to effectively communicate bad news. Although there is little research on this subject, studies suggest that physicians feel inadequately trained in sharing bad news, but after receiving structured training in the area, feel more comfortable engaging in these conversations.1

The Many Reasons We Avoid It

Besides lacking specific training in the area, medical professionals may avoid sharing bad news for a number of other reasons. We may feel personally responsible for a patient’s misfortune or feel that a poor outcome reflects a practice failure. Clinicians also often worry that sharing bad news will cause adverse reactions in patients, such as anxiety or despair. Finally, unresolved personal issues surrounding the death and dying process can also adversely affect a hospice professional’s ability to communicate bad news.

A 6-Step Protocol that Can Help

Although there is no evidence-based consensus on the best way to share bad news, experience suggests that structured communication is more effective than ad lib discussions. In his book, How to Break Bad News: A Guide for Health Care Professionals, Dr. Robert Buckman proposed a six-step protocol that many find helpful when embarking on a difficult conversation. His protocol uses the mnemonic, SPIKES, to help clinicians remember the content and order of the important steps, summarized below:

S—Setting

First, ensure the setting is conducive to good communication. Adequate privacy and comfort for the patient and family is essential. Limit distractions by turning off cell phones and pagers, and ask staff members to avoid interrupting the meeting. Invite appropriate loved ones to the conversation but, at the same time, respect the patient’s privacy and autonomy by excusing unwanted family members. Always remember to minimize any sense of power inequity by speaking to patients at their eye level.

P—Perception

Next, elicit the patient’s perception of the current problem. Psychological defense mechanisms, such as denial, can affect a patient’s capacity to understand the prognosis. Furthermore, when patients see multiple specialists it is easy for them to receive inconsistent or even conflicting information. It is unwise to begin sharing diagnostic or prognostic information without first knowing the patient’s current understanding of the circumstances.

I—Invitation

Before sharing bad news with patients, obtain an invitation to proceed. Patients who are in pain or experiencing other physical symptoms may want to postpone the conversation. The information will be better understood if the patient is physically and emotionally ready to receive it.

K—Knowledge

When it is time to share the specific bad news with the patient, share the knowledge in small chunks. It is tempting for clinicians to disclose everything they know about the patient’s condition at once. Sharing too much information at one time reduces the likelihood that a patient will understand and remember the details. Avoid using medical jargon. While this advice is self-evident, it is easy to forget that even what we think of as simple medical terms, like “malignancy” or “prognosis,” can be misunderstood by the patient or family member. Stop and check frequently for understanding.

E—Empathy

Once you have shared some information about the patient’s condition and checked for knowledge, it is time to begin to understand the impact on the patient. Avoid using trite phrases like “I understand” or “I know how you must feel.” Instead, simply ask how he or she is feeling. Reflect on the patient’s emotions and let the patient know that you understand how and why he or she feels that way. Although it is not necessary to literally assume the burden of the patient’s feelings, if the patient feels empathy, it can be disarming and reassuring. True empathy with the patient or family member can have a powerful impact on the therapeutic relationship. When patients feel they are heard and understood by their caregivers, they are more likely to trust them and follow their advice.

S—Summarize and Strategize

Learning difficult news can be overwhelming to patients and family members. Medical details, particularly when patients are seriously ill, are often complicated. Make sure you end the conversation by summarizing the information and discussing a future strategy.

Learning how to deliver bad news and discussing goals of care in a structured manner—so patients and their loved ones are ready to hear the information, understand it, and feel listened to and cared for—can better equip them to make decisions that are consistent with their values and the goals of care. In short, patients can get the care they want, where they want it.

About the Author

Kevin Henning, MD, FAAFP, FAAHPM, is chief medical director of Amedisys Home Care and Hospice. He is a nationally recognized leader in hospice and palliative medicine.

References:

  1. Walter F. Baile, M.D. Cancer 1999;86:887–97
  2. Buckman, R. (1992). How to Break Bad News: A Guide for Health Care Professionals. Baltimore: Johns Hopkins University Press.
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Holistic Palliative Care for Alzheimer's/Dementia Patients

Posted 1/3/2012 Categories: chronic care, palliative care, dementia, hospice, webinar, alzheimer's

Alzheimer’s disease is the sixth leading cause of death in the United States and accounts for the largest percentage of dementia cases. For patients with end-stage Alzheimer’s disease and other forms of dementia, palliative and hospice care professionals can achieve optimal results by providing holistic end-of-life care services.

As part of their interdisciplinary topics series, the National Hospice and Palliative Care Organization (NHPCO) is hosting a webinar to discuss the importance of interdisciplinary team collaboration in assessing and holistically treating these patients and supporting their families.

Amedisys Chief Medical Officer, Dr. Kevin Henning, and China Phillips, Nurse Practitioner at Columbus Hospice, will:

  • identify pharmacological and non-pharmacological treatment options
  • discuss behavioral issues associated with patients with dementia
  • offer strategies with a focus on nursing and other interdisciplinary team member interventions to help families adapt to the day-to-day challenges of caring for a loved one with advanced dementia.

For more info and registration:

January Interdisciplinary Topic Holistic Palliative Care for Alzheimer/Dementia Patients
January 12, 2012 - 2:00 pm - 3:30 pm ET
CE/CME Offered: Counselor, Nurse, Physician, and Social Work

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