bluuebunny/crossref_metadata_2025 huggingface dataset:
Breakthrough strong opioid analgesia prescription in patients using transdermal fentanyl admitted to a hospice
Authors: Lawrie Iain , Lloyd-Williams Mari , Waterhouse Esther
Published: May 2006

Durogesic ® (fentanyl) patches have revolutionized pain relief, but patients still require breakthrough medication. A retrospective analysis of in-patient admission notes at a 25-bed hospice over a six-month period was carried out. Details of analgesia being used on admission for both background and breakthrough pain were obtained, and the appropriateness of the breakthrough dose for those patients using transdermal fentanyl was determined. During the study period, 278 patients were admitted to the hospice and 56 (20 percent) were using transdermal fentanyl. Of these, 35 (62 percent) were prescribed strong opioid analgesia—the dose of breakthrough medication prescribed was appropriate in 11 patients (31 percent). Rescue dosing was less than recommended, in relation to prescribed transdermal fentanyl strength, in 21 patients (60 percent) and greater than recommended in one patient (3 percent). In this study, short-acting strong opioid analgesia was not always prescribed for patients using transdermal fentanyl, and when they were prescribed, this was in the appropriate dose range in less than a third of patients.
Hospice fraud and abuse: Operation Restore Trust and beyond
Authors: Morris Gerald M.
Published: May 2006

Medicare-funded hospice is at a crossroad. It is estimated that in the year 2000, of the 2.4 million Americans who died, one in four used hospice. The demand for hospice services is projected to grow as the baby-boomer population continues to age and experiences the health issues that come with it.

Yet evidence suggests the program is failing to fulfill its statutory purpose as a meaningful benefit to many, particularly those with noncancerous conditions. The causes for this include unwieldy eligibility criteria and the chilling effect of aggressive fraud enforcement.

The unique nature and scope of hospice services available under Medicare, and their complex interrelationship with other Medicare benefits, all contribute to the errors and fraud graphically illustrated by government enforcement activities.

Operation Restore Trust and similar enforcement activities may be restoring confidence that inappropriate expenditures are being wrung out of the hospice system. But at the same time, they are also creating distrust, particularly among those with noncancerous conditions, about whether they will receive the benefits for which they are eligible and to which they are entitled. In part, this is a consequence of the chilling effect (real or perceived) that aggressive enforcement is having on physicians and hospice medical directors who certify eligibility to the program.

This paper reviews the Medicare hospice benefit, identifies the more significant fraud and abuse issues that hospice presents, examines the impact of Operation Restore Trust and other compliance activities on hospice, and makes final observations about the future.
Hospice and primary care physicians: Attitudes, knowledge, and barriers
Authors: Ogle Karen , Mavis Brian , Wang Tammy
Published: May 2006

Underuse of hospice services is a significant problem in the United States. Primary care physicians constitute an increasing referral base and have been hypothesized to be important barriers to increased use. We conducted a mail survey of 131 primary care physicians (overall response rate of 72 percent), examining their attitudes toward, knowledge about, and perceived benefits and barriers to hospice care. Physicians demonstrated very favorable attitudes towards hospice. They had correct knowledge about most aspects of hospice, and, where they did not, they were far more likely to be uncertain than erroneous. Primary care physicians perceived many benefits to hospice care and identified patient and family readiness as the major barrier to earlier hospice referrals. A significant subgroup had concerns about problems in interacting with hospices. There were very few differences between family practitioners and general internists. These findings have many implications for directing collaborative efforts between primary care physicians and hospices to improve end-of-life care.
Phenol saddle blocks for intractable pain at end of life: Report of four cases and literature review
Authors: Slatkin Neal E. , Rhiner Michelle
Published: May 2006

Four cancer patients with prior bladder diversions had phenol neurolytic saddle blocks performed for intractable pelvi-sacral pain. All patients had advanced disease, the focus of their treatment being palliative. Treatment limiting side effects precluded further upward titration of systemic analgesic therapies. Pain control improved after intrathecal neurolysis and allowed a greater than 60 percent reduction in systemic opiate dosage. No significant block-related adverse effects were encountered. The value and technical aspects of intrathecal saddle blocks in end-of-life pain management is discussed.
Complicated bereavement: A national survey of potential risk factors
Authors: Ellifritt Julia , Nelson Kristine A. , Walsh Declan
Published: May 2006

We developed a Bereavement Risk Questionnaire to rate 19 possible factors for assessing complicated bereavement. A four-point scale was used (0 = no risk, 3 = significant risk). The questionnaire was mailed nationwide in the United States to 508 hospice bereavement coordinators, and 262 responded. Most rated the following as significant risks: perceived lack of caregiver social support (70 percent), caregiver history of drug/alcohol abuse (68 percent), caregiver poor coping skills (68 percent), caregiver history of mental illness (67 percent), and patient is a child (63 percent). Overall, 61 percent chose perceived lack of social support, and 47 percent chose poor coping skills, as one of the top three risk factors. There was no relationship between professional discipline and responses. We found a consensus among bereavement professionals regarding important indicators in assessing bereavement risk. We conclude that it is possible to assess bereavement risk in caregivers of seriously ill patients, prior to the death of the patient. This would allow palliative care teams to allocate resources and services to those at the greatest risk for complicated bereavement.
Hospice patients’ attitudes regarding spiritual discussions with their doctors
Authors: Hart Alton , Kohlwes R. Jeff , Deyo Rick , Rhodes Lorna A. , Bowen Deborah J.
Published: May 2006

The purpose of this study was to assess hospice patients’ attitudes regarding the discussion of spiritual issues with their physicians. We conducted in-depth interviews using open-ended questions on living with illness, spirituality and religion, and physician-patient relationships. The interviews were audiotaped, transcribed, and analyzed for dominant themes. The following dominant themes were identified: (1) treating the whole person, (2) treating with sensitivity, (3) favorable attitudes toward religious or spiritual discussions with doctors, and (4) no “preaching.” Our findings suggest that patients do not expect physicians to be their primary spiritual advisors; however, physicians should be aware of and comfortable communicating with patients about religious or spiritual issues. More training in this topic may enhance the care physicians provide to patients near the end of life.
Comparison of hospice use and demographics among European Americans, African Americans, and Latinos
Authors: Colón Merydawilda , Lyke Jennifer
Published: May 2006

The goals of this study were to compare the rate of use of hospice services and other relevant characteristics of European American, African American, and Latino hospice patients. Information on length of stay in hospice, marital status, age, disposition at termination, living situation, caregiver, referral source, and payment method was collected on patients who used hospice care in southern New Jersey between the years 1995 and 2001 (N = 1958). African Americans and Latinos were both found to use services at significantly lower rates than European Americans. In addition, African American use of hospice declined significantly during this time period, while European American use increased. Differences were also found among the groups in marital status, living situation, caregiver, referral source, and payment method. These differences highlight the need for hospice providers to recognize issues unique to minority groups. The reasons for these disparities need to be clarified by further research.
Characteristics of dementia end-of-life care across care settings
Authors: Volicer Ladislav , Hurley Ann C. , Blasi Zuzka V.
Published: May 2006

End-of-life care for persons with dementia in different care settings was retrospectively surveyed. In this sample, care recipients receiving hospice care and pain control stayed at home longer and were more likely to die at home. Psychiatric symptoms increased caregiver burden and were the most common reason for admission to an institution, and psychiatric care was associated with longer stay at home. Presence of advance directives decreased hospital stay and increased the likelihood of dying in a nursing home. Care recipients dying at home had fewer symptoms and less discomfort than care recipients dying in other settings. These results indicate that quality end-of-life care can be provided at home and is facilitated by hospice programs, effective pain control, and psychiatric care.
Developing end-of-life interdisciplinary programs in universitywide settings
Authors: Gelfand Donald E. , Baker Lynda , Cooney George
Published: May 2006

Interdisciplinary programs in end of life are widely discussed as valuable, particularly approaches to end-of-life care. Despite this emphasis, interdisciplinary programs have not been easy to implement. In universities, the implementation of interdisciplinary programs encounters administrative obstacles, including credit for the time spent in these group efforts and “ownership” of interdisciplinary courses (IDCs). This article details the process of development and the activities of an end-of-life interdisciplinary program at one urban university with a major medical center. The issues faced in the first year are examined. These included trust, group identity, and communication. The lessons from the first-year activities are presented and efforts of the second year described.
Caregivers’ satisfaction with hospice care in the last 24 hours of life
Authors: Casarett David J. , Hirschman Karen B. , Crowley Roxane , Galbraith Linda D. , Leo Melinda
Published: May 2006

The goals of this study were to identify elements of care that contributed to positive and negative perceptions of hospice care in the last 24 hours of life, and to define patient and family characteristics that are associated with satisfaction with care during this difficult period. Surveys were sent to 207 primary caregivers, and 112 surveys were returned. This study reports four findings that elucidate the factors that make family members more or less satisfied with the care that their loved one received during the last day of life, and how satisfaction with this period of care should be measured.
The RAI-PC: An assessment instrument for palliative care in all settings
Authors: Steel K. , Ljunggren G. , Topinková E. , Morris J. N. , Vitale C. , Parzuchowski J. , Nonemaker S. , Frijters D. H. , Rabinowitz T. , Murphy K. M. , Ribbe M. W. , Fries B. E.
Published: May 2006

Large numbers of persons in most types of healthcare settings have palliative care needs that have considerable impact on their quality of life. Therefore, InterRAI, a multinational consortium of researchers, clinicians, and regulators that uses assessment systems to improve the care of elderly and disabled persons, designed a standardized assessment tool, the Resident Assessment Instrument for Palliative Care (RAI-PC). The RAI-PC can be used for both the design of individual care plans and for case mix and outcomes research. Some elements of this instrument are taken from the resident assessment instrument (RAI) mandated for use in all nursing homes in the United States and widely used throughout the world. The RAI-PC can be used alone or in conjunction with the other assessment tools designed by the InterRAI collaboration: the RAI for homecare (RAI-HC), for acute care (RAI-AC), and for mental health care (RAI-MH).

The objective of this study was to field test and carry out reliability studies on the RAI-PC. After appropriate approvals were obtained, the RAI-PC instrument was field tested on 151 persons in three countries in more than five types of settings. Data obtained from 144 of these individuals were analyzed for reliability. The reliability of the instrument was very good, with about 50 percent of the questions having kappa values of 0.8 or higher, and the average kappa value for each of the eight domains ranging from 0.76 to 0.95. The 54 men and 95 women had a mean age of 79 years. Thirty-four percent of individuals suffered pain daily. Eighty percent tired easily; 52 percent were breathless on exertion; and 19 to 53 percent had one or more other symptoms, including change in sleep pattern, dry mouth, nausea and vomiting, anorexia, breathlessness at rest, constipation, and diarrhea. The number of symptoms an individual reported increased as the estimated time until death declined. The “clinician friendly” RAI-PC can be used in multiple sites of care to facilitate both care planning and case mix and outcomes research.
Dying to meet you: Facing mortality and enabling patient styles
Authors: Stolick Matt
Published: May 2006

This paper is intended to emphasize the existence of prognostic uncertainty in providing survival estimates while also providing a method for caring to those who want to authentically help dying patients. Facing one’s own mortality helps one compassionately be there for dying patients. The transforming experience of death as essential to one’s self as human being, recognizing that one is living a story with death necessarily a part, promises to overcome the tendency to deny the existential meaning of death for dying patients. This tendency manifests itself through dishonesty about medicine’s limitations in creating prognoses, and specifically survival estimates, as well as in holding only a curative and not palliative goal of treatment. This tendency will be replaced by honest and compassionate actions with those in the process of dying. Representing this change is a focus on the patient as person, living a certain lifestyle, and defining himself by significant events and relationships in the past, present, and future. Death and dying become meaningful through incorporation into the story and style that is the patient. This meaning that is facilitated by caregivers and created by patients is central to achieving a “good death.”
Hospice care in prison: General principles and outcomes
Authors: Yampolskaya Svetlana , Winston Norma
Published: May 2006

In recent years, tougher sentencing laws have resulted in larger numbers of elder prison inmates and, consequently, more deaths occurring in prisons. In this context, the introduction of prison hospice programs takes on great significance. The purpose of this study is to identify the principle components and outcomes of prison hospice programs based on data gathered from semistructured telephone interviews with prison hospice providers in state and federal correctional institutions and from other sources. The results suggest that there is a growing effort to provide palliative care to dying inmates across the country and that all of the existing programs share common elements and similar structures. Major outcomes of prison hospice programs include cost-effectiveness, enhanced correction, and comfort care.
Meloxicam and selective COX-2 inhibitors in the management of pain in the palliative care population
Authors: Smith Howard S. , Baird Whitney
Published: May 2006

This paper discusses the treatment of pain in the palliative care patient, specifically the use of meloxicam and recent advances in agents with cyclooxygenase-2 (COX-2) selectivity. Meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) that preferentially inhibits COX-2 more than cyclooxygenase-1 (COX-1), especially at low doses, thereby offering advantages over traditional nonselective NSAIDs. New COX-2 selective agents are discussed, including valdecoxib, parecoxib, etoricoxib, and COX-189.
End-of-life care education in United States pharmacy schools
Authors: Herndon Christopher M. , Jackson Kenneth , Fike David S. , Woods Tresa
Published: May 2006

Hospice and palliative care have undergone dramatic changes in the past 30 years. Educational initiatives and certification programs for physicians (American Board of Hospice and Palliative Medicine) and nurses (National Board for Certification of Hospice and Palliative Nurses) have further delineated this area of practice as distinct from geriatrics, neurology, anesthesiology, or oncology. As other professions assess their own practices of hospice and end-of-life (EOL) care education in their respective schools and colleges, the pharmacy profession must also ensure that its future graduates are prepared to adequately participate in this type of care.

This was a descriptive study in which all accredited schools and colleges of pharmacy in the US were queried regarding their level of curricular commitment to EOL care. Eighty-three questionnaires were mailed, and 60 schools responded (72 percent). Four primary informational items regarding EOL and palliative care education were targeted, including availability of didactic teaching, specialization of pharmacy faculty, availability and type of clerkships, and method of instruction. Sixty-two percent of respondents indicated EOL care education was provided didactically (3.89 ± 1.91 lecture hours per year). Fifty-eight percent of respondents indicated that EOL care experiential clerk-ships were available (4.97 ± 1.25 weeks in duration). These data indicate that over half of US pharmacy students receive some exposure to EOL care education.
Toward evidence-based prescribing at end of life: A comparative review of temazepam and zolpidem for the treatment of insomnia
Authors: Bain Kevin T. , Weschules Douglas J. , Knowlton Calvin H. , Gallagher Rollin
Published: May 2006

A comparative review of temazepam and zolpidem use in managing insomnia in the hospice patient was undertaken to determine whether treatment with temazepam is a more cost-effective approach for this patient population.

A MEDLINE search was conducted to identify pertinent literature, including clinical trials and reviews that involved temazepam or zolpidem. Published data was used as background information and provided in the discussion.

This retrospective analysis, conducted from June 2002 through November 2002, focused on the prescribing patterns of temazepam and zolpidem in our hospice practice setting. We examined the reasons for discontinuation of each agent, along with the frequency of therapeutic change from temazepam to zolpidem. The top 10 ICD-9 codes associated with each treatment modality were investigated to determine any prescribing patterns.

A total of 4,752 participants were prescribed either temazepam or zolpidem during this six-month period. Of the 4,065 patients prescribed temazepam 9.9 percent had the agent discontinued, whereas, 13.0 percent of those taking zolpidem (n = 687) terminated therapy. Reasons for discontinuation included change in dose, incomplete efficacy, change in patient status, adverse drug reaction, cultural/social issues and “other.” Analyses of prescribing patterns and the reasons for termination of each drug therapy were completed and compared with results found in the primary literature.

Due to the limited financial resources available for hospice care, our goal is to provide the most clinically appropriate and cost-effective agents for hospice patients. With the lack of data pertaining to the hospice patient, physicians often are faced with challenges in deciding the most appropriate therapy. They may prefer one agent over another based on current medical opinion rather than sound clinical evidence. After review of the primary literature and the prescribing patterns in our setting, there is currently no evidence in our patient population to support that zolpidem is superior to benzodiazepines for the treatment of insomnia.
A palliative medicine program in a community setting: 12 points from the first 12 months
Authors: Cowan John D. , Burns Debbie , Palmer Teresa Walker , Scott Jerry , Feeback Emily
Published: May 2006

This paper reports the first year’s experience of a consultative, interdisciplinary, integrated palliative medicine program in a community hospital system. Prospective data collection was performed on 308 consecutive consultations. A computer database was developed and used to analyze demographics, reason for consultation, complexity of medical problems, current medications and allergies, physical suffering, spiritual concerns, personal and family concerns, consult recommendations, and mortality. In addition, data were collected on patient rating of the severity of physical symptoms, pain, spiritual suffering, and personal and family suffering; this data also was analyzed using the database.

Cancer was the most frequent diagnosis (34 percent) and pain the most common reason for consultation (43 percent). Population medians were identified as follows: five (range, 1 to 10) acute medical problems; three (range, 1 to 10) chronic medical problems; and one (range, 0 to 10) medication allergy/intolerance. Patients were taking a median of 10 (range, 0 to 29) medications, including a median of two analgesics. Eighty percent could communicate concerning physical symptoms and had a median of two (range, 0 to 7) bothersome symptoms, with pain the most frequent. Fifty percent or fewer could rate physical suffering, pain, hope, spiritual suffering, or personal/family suffering using a 0 to 10 scale at consultation. Individual patient ratings provided over time for physical suffering, pain, hope, spiritual suffering, and personal/family suffering were available for less than 25 percent. A median of eight recommendations was made for each consultation, with medication changes suggested for 84 percent. For those known to have died, the median survival from time of consultation to death was 11 days.
Morphine hyperalgesia: A case report
Authors: Wilson George R. , Reisfield Gary M.
Published: May 2006

We report a case of a patient with metastatic testicular cancer and intractable pain refractory to massive doses of oral, intravenous, and intrathecal (IT) opioids supported by analgesic adjuvants. During our efforts to control his pain, the patient exhibited opioid-induced hyperalgesia, an uncommon but important phenomenon seen with high-dose opioid therapy. With appropriate opioid adjustment—in this case reduction of intrathecal morphine dosage by a factor of 100—the condition rapidly resolved and the patient became pain-free and remained so until his death six weeks later. The keys to identifying this uncommon, but treatable, opioid side effect are recognizing it as a possibility when aggressive efforts to control pain with high doses of opioids, especially when administered neuraxially, are met with increasing pain.
Subcutaneous emphysema: An uncommon presentation of enterocutaneous fistula
Authors: Correoso Lyla J. , Mehta Rekha
Published: May 2006

Patients with advanced cancer often develop enterocutaneous fistulae. The enterocutaneous fistulae usually develop from gastrointestinal malignancies. We describe a case report of a patient with schwannoma of the ovarian cyst wall who developed enterocutaneous fistula but presented with subcutaneous emphysema.
Understanding of the term “palliative care”: A Canadian survey
Authors: Claxton-Oldfield Stephen , Claxton-Oldfield Jane , Rishchynski Giselle
Published: May 2006

This article examines the results of two studies conducted in Atlantic Canada to evaluate people’s understanding of palliative care. In Study 1, a sample of adults were asked to respond to a brief survey. Respondents were asked if they had ever heard of palliative care. Those who answered “yes” were asked to respond to a number of additional questions about palliative care. The results of Study 1 revealed that over three-quarters of the respondents (75.3 percent) had heard of palliative care, however, only about half of these (48.4 percent) defined it as care for terminally ill or dying persons. Of those who had heard of palliative care, the vast majority (92.3 percent) said they would use palliative care services if they had a terminally ill family member.

In Study 2, respondents were presented with a written description of palliative care. After reading the description, respondents were asked to indicate whether or not they knew (prior to reading the description) what palliative care was. Those who answered “yes” were asked to provide a written explanation of how they first learned about palliative care; those who answered “no” were asked to provide written suggestions of how they believed information about palliative care should be disseminated to the public. The results revealed that 60.5 percent of the respondents knew about palliative care before reading the description. Of those who knew about palliative care, 40.8 percent of them first learned about it through personal experience with the death of a family member or close friend. Of those who did not know what palliative care was, the suggestions they gave for creating community awareness of palliative care included: information disseminated by healthcare providers, use of pamphlets, the media, and the church.
Which primary care resident is more likely to initiate the discussion of designating a healthcare proxy?
Authors: Eloi-Stiven Marie L. , Tobias Maria Melissa S. , Finkel Madelon , Lopez-Luciano Luisa , Kondamudi Vansantha , DeLaRosa Maritza
Published: May 2006

Despite widespread support for the concept of advance care planning, few Americans have a healthcare proxy. It is not known if certain physician characteristics make it less likely that the discussion of a healthcare proxy will be initiated, particularly in the case of physicians in training.

The objective of this descriptive, cross-sectional study was to determine if resident characteristics (specialty, race, age, gender, and religion) affect his or her decision to initiate discussions with patients regarding designation of a healthcare proxy.

Participants consisted of primary care residents employed at The Brooklyn Hospital Center, Brooklyn, New York, from the departments of Internal Medicine, Pediatrics, Obstetrics and Gynecology, and Family Practice. An anonymous 14-item questionnaire was distributed to all primary care residents (N = 151) at the hospital during their respective conferences and grand rounds. Seventy-eight residents returned the instrument for analysis.

When compared to other primary care specialties (n = 40), internal medicine residents (n = 38) were more likely to initiate healthcare proxy discussions with patients (p < 0.05). Residents who were younger than 35 were more inclined to encourage decision-making by surrogates (p < 0.05). Of the total number of residents, 92 percent correctly defined a healthcare proxy, and 66 percent thought a physician should initiate patient selection of a healthcare proxy, yet only 55 percent of physicians did so.

Our results indicated that a little over half of the physicians surveyed initiated discussion for a surrogate decision-maker, even though most thought it was their duty. Younger internal medicine residents are more likely to ask patients about healthcare proxies. Some residents were unable to correctly identify the definition of a healthcare proxy, and this lack of knowledge is likely to result in poor advance care planning.
The conversion challenge: From intrathecal to oral morphine
Authors: Sylvester Robert K. , Lindsay Stephanie M. , Schauer Caroline
Published: May 2006

Numerous articles have described the methodologies used and outcomes achieved with the intrathecal (IT) administration of morphine for pain. However, only one case report has been published that describes converting a patient’s IT morphine to an oral regimen. This case report describes the experience of converting a patient’s IT morphine to oral morphine and discusses the scarcity of published data to validate suggested equianalgesic intraspinal morphine recommendations. The calculated equianalgesic oral to IT ratio in this case was 12:1. This is substantially lower than the 300:1 ratio published by Krames and the 90:1 ratio employed by a commercially available software program for calculating equianalgesic opioid doses. We recommend caution when applying existing guidelines for conversion of morphine from an IT to an oral regimen.
Hospital charges for a community inpatient palliative care program
Authors: Cowan John D.
Published: May 2006

Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of $65,795, and mean daily charges of $3,809. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of $3,117. These mean daily charges were $414 less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test).

The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas ® (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of $4,105 (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001).

Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than $100,000 per year, and estimated savings achieved using AIA follow-up charges were more than $1,801,930 per year.
Religious maturity in the midst of death and dying
Authors: Kacela Xolani
Published: May 2006

Healthy religious experience is defined by certain qualities of expression. In an effort to explore the concept of mature religious phenomenology, this article includes descriptions of two encounters from personal pastoral experience. The first encounter shows how a person with an unhealthy religious experience faces death. The second encounter describes an expression of mature religious experience in the face of death and how a pastoral caregiver can facilitate its outcome. This is followed by a pastoral theological response.
Joining forces, joining futures: Hospice at the crossroads
Authors: Pietroburgo Julie
Published: May 2006

Faced with health-policy changes, increased competition, and limited funding, hospices must either find more efficient ways to provide end-of-life care or risk organizational demise. Increasingly, hospices are re-evaluating their organizations to stretch resources and remain viable. Prevalent restructuring options for addressing environmental pressures are integration, alliance, and collaboration with other organizations. This study examines the restructuring phenomenon by evaluating trends among nonprofit hospices in six states. The study identifies demographic characteristics predictive of organizational decisions to join forces, and it examines the dominant political and economic reasons that propel or impede restructuring decisions. In addition, the study evaluates the results of restructuring actions.
The business of palliative medicine—Part 4: Potential impact of an acute-care palliative medicine inpatient unit in a tertiary care cancer center
Authors: Walsh Declan
Published: May 2006

In this study, a hematology/oncology computerized discharge database was qualitatively and quantitatively reviewed using an empirical methodology. The goal was to identify potential patients for admission to a planned acute-care, palliative medicine inpatient unit. Patients were identified by the International Classifications of Disease (ICD-9) codes. A large heterogenous population, comprising up to 40 percent of annual discharges from the Hematology/Oncology service, was identified. If management decided to add an acute-care, palliative medicine unit to the hospital, these are the patients who would benefit. The study predicted a significant change in patient profile, acuity, complexity, and resource utilization in current palliative care services. This study technique predicted the actual clinical load of the acute-care unit when it opened and was very helpful in program development. Our model predicted that 695 patients would be admitted to the acute-care palliative medicine unit in the first year of operation; 655 patients were actually admitted during this time.
Gefitinib: A new agent in palliative care
Authors: Prommer Eric
Published: May 2006

In 2003, gefitinib (Iressa ® , AstraZaneca, London, UK) in 250 mg tablet form received accelerated approval by the US Food and Drug Administration. Gefitinib targets the cancer cell at the molecular level and has the ability to palliate lung cancer symptoms. Gefitinib’s ability to control symptoms with minimal toxicity provides physicians with a new option to complement current symptom control methods. It is nonmarrow suppressive and seems to have an ability to control symptoms quickly, even in the absence of obvious tumor reduction. However, further studies are needed to compare gefitinib’s ability to control symptoms with intensive palliative modalities for lung cancer, such as opioids, oxygen, and radiation therapy.
Psychological models that help hospice workers perform mental status evaluations
Authors: Crawford Aubrey A.
Published: May 2006

All hospice workers share responsibility for emotional support of patients. The effectiveness of this support depends on accurate assessments of patients’ mental and emotional status. The use of psychological models assist in understanding patients and make it easier to develop appropriate and effective interventions. Several psychological models are used to 1) assist in the spiritual care or supportive counseling of patients who seek to resolve issues or find closure in their lives; or 2) support patients who exhibit patterns of avoidance and denial, supplemented by appropriate medications.
Measuring preparedness to address patient preferences at the end of life
Authors: Kane Michael N. , Hamlin Elwood R. , Hawkins Wesley E.
Published: May 2006

This study investigated the factor structure of an instrument to measure preparedness perception among Florida licensed clinical social workers for work with elders’ end-of-life care. In a principle component analysis with varimax rotation, three factors were identified with eigenvalues greater than 1.0 and a cumulative variance of 66.982 percent. These factors include: 1) knowledge of end-of-life care, 2) knowledge of resources for elders, and 3) attitude toward elder assisted suicide. The development of this type of instrument may be useful for future research and for determining future educational needs of social workers and other professionals.
Association of admission date with cancer patient survival at a regional hospice: Utility of a statistical process control analysis
Authors: Mertens Wilson C. , Hoople Nancy E. , Rodrigues Carol , Lindenauer Peter K. , Benjamin Evan M.
Published: May 2006

Previously published multivariate analyses have not considered date of entry as a possible factor associated with length of stay (LOS), nor has the pattern of decreasing LOS been analyzed. We set out to assess mean LOS over time and to determine the factors, including date of death, which are independently associated with LOS. Cancer patients admitted to our hospice from 1996 through 2001 were assessed for dates of admission/discharge/death, age, gender, race, specific cancer diagnosis, referring physician characteristics, place of death, and heath insurance type. Statistical process control (SPC) charts and proportional hazard models were constructed for patients prioritized by date of admission, with active or discharged patients censored. A total of 2126 patients were analyzed. An abrupt and significant drop in mean LOS was seen for all cancer patients and for most cancer sites from April to December 1998 (temporally associated with a “Special Fraud Alert” issued by the Office of Inspector General) and again in the second and third quarter of 2000. A proportional hazards model revealed that LOS was associated with cancer site (p < 0.0001), quarter in which patient was admitted (p = 0.0020), and sex (women surviving longer, p=0.013), age (older patients surviving longer, p 0.0149), and insurance (p = 0.071). Mean LOS is associated with date of admission to hospice independent of other associated factors. LOS decreases do not occur in a gradual, continuous fashion but suddenly and intermittently, and they are not associated with changes in referral numbers or read-missions. SPC charts proved to be an effective method of tracking and evaluating hospice LOS on an ongoing basis.
Estimating goodwill: An application of Pine’s procedures for hospices
Authors: Doka Kenneth J. , Pine Vanderlynn
Published: May 2006

Hospice care is a philosophy as well as a business. As a business, especially in the current healthcare environment, it is subject to many of the same forces that affect other businesses, such as acquisitions, sales, and mergers. Yet, estimating the value of a hospice is problematic, since its most valued asset (the reputation and goodwill that it has generated within the communities it serves) is intangible. This article explores the problem of assessing the value of a hospice, applying Pine’s model for estimating goodwill in funeral service as a useful approach for hospices. The article offers assumptions for assessment and examples of suggested approaches.
Hospice staff attitudes towards telehospice
Authors: Demiris George , Oliver Debra R. Parker , Fleming David A. , Edison Karen
Published: May 2006

Telemedicine, defined as the use of advanced telecommunication technologies to bridge geographic distance and improve delivery of care, is perceived by many as a way to eliminate barriers to quality care at the end of life. The use of telemedicine in hospice, known as telehospice, is a novel approach to such care, and few pilot studies have investigated its feasibility. The purpose of this study was to assess hospice providers’ perceptions of telehospice. A focus group session was conducted with 10 staff members from five hospice agencies in Missouri. Participants included administrators, nurses, and social workers. Overall, providers had a positive perception of telehospice and found that the use of videophone technology enhanced care by enabling providers, patients, and family members a means to communicate. However, they emphasized that it was an additional tool and not a substitute for actual visits. Issues of privacy and usability were also raised.
The cost of breathing: An economic analysis of the patient cost of home oxygen therapy
Authors: Reisfield Gary M. , Wilson George R.
Published: May 2006

The oxygen concentrator is a popular means of delivering supplemental oxygen to the home hospice patient. The technology is notable for its reliability, convenience, and ease of use. It is the most cost effective of the various oxygen delivery systems from the institutional standpoint. Cost effectiveness from the patient standpoint has not previously been reported. We present a brief analysis of the cost of operating such a device from the perspective of the patient and suggest possible ways of addressing this cost.
Establishing the safety and efficacy of an opioid titration protocol
Authors: Wells Nancy , Murphy Barbara , Douglas Stacey , Yelton Nancy
Published: May 2006

The primary goal of this single-group study was to determine the safety of a standard opioid titration order sheet to manage pain in ambulatory cancer patients. Secondary goals were to examine opioid toxicity and efficacy of this pain protocol.

Twenty-seven patients who required fixed-dose opioids and who had uncontrolled pain were enrolled. All patients had their initial opioid dose titrated by the study physician using the opioid titration order sheet. Data were obtained by the study nurse during a weekly telephone interview and used to determine if pain was controlled. After initial titration, a trained study nurse titrated opioid doses based upon the standing order sheet. At each contact, patients were assessed for adverse effects, pain intensity, and analgesics used.

Patients who completed the four-week trial (n = 17) did not differ from patients who did not complete the trial. No adverse effects were observed in 39 opioid titrations completed by the study nurse. Opioid toxicities, worst pain, usual pain, and pain-related distress declined from baseline to week four. Patients who were adherent to their prescribed medications reported significantly lower pain intensity and distress (psα .06).

The opioid titration order sheet, used by a trained nurse, is safe to use in ambulatory cancer patients who have moderate to severe pain. Common opioid toxicities were reduced. The protocol also demonstrated initial efficacy in improving worst and usual pain and pain-related distress. Further research to establish efficacy of the protocol is recommended.
Medical house officers’ attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide
Authors: Kaldjian Lauris C. , Wu Barry J. , Kirkpatrick James N. , Thomas-Geevarghese Asha , Vaughan-Sarrazin Mary
Published: May 2006

In 2000, the authors surveyed 236 medical house officers in three internal medicine residency programs in Connecticut to assess attitudes toward vigorous analgesia, terminal sedation, and physician-assisted suicide. The goal was to identify associations between these attitudes and training, demographic, and religious factors.

The results of the study indicated that most medical house officers supported vigorous analgesia, the majority supported terminal sedation, but only a minority supported physician-assisted suicide. Some house officers’ attitudes toward terminal sedation and assisted suicide may have been influenced by their religious commitments and the pressures of training.
Information needs of family caregivers of terminal cancer patients in Taiwan
Authors: Lin Wei-chun , Tsao Chao-jung
Published: May 2006

Previous studies have indicated that when family caregivers are provided with enough of the right information their coping strategies in caring for terminal cancer patients are enhanced. In Taiwan, family caregivers are highly involved in their ill family member’s symptom management and must stay at the bedside to share the nursing and caregiving tasks in the palliative care unit. The cross-sectional survey described here used a structured questionnaire to identify six domains of information needed among family caregivers who stay in the palliative care units to prepare them to provide hospice homecare after discharge. The six domains for which family members needed specific information included the basic tenets of caregiving, the disease, the social welfare of the patient, psychosocial issues, palliative care, and spirituality/religion. This study indicated that information about the disease itself was of greatest importance, with the least importance attached to spiritual and religious information. Age, gender, educational level, and socioeconomic status (SES) of family caregivers were factors in how they viewed the importance of each domain. Situation-related variables, such as the extent of each caregiver’s role in decision making, duration of the patient’s disease, and the treatment the patient was undergoing were also related to how caregivers valued each type of information. Study results indicated that the education of caregivers in the palliative care unit should be individualized based on each patient’s condition and each family’s characteristics.
Pacemaker and defibrillator deactivation in competent hospice patients: An ethical consideration
Authors: Ballentine Jennifer M.
Published: May 2006

The Denver Community Bioethics Committee (DCBC) is an independent, community-based group that undertakes ethics consultations for any individual or organization. Its members include adult protection professionals, physicians, elder-law attorneys, chaplains, nurses, social workers, and lay persons. In its 11-year history, the Committee has heard numerous cases concerning end-of-life care, futile treatment, and patients’ rights.

In 2003, a Colorado hospice provider asked the DCBC for assistance in developing a policy on deactivation of pacemakers and defibrillators in competent hospice patients. The hospice had encountered concerns from some physicians and cardiac care clinicians that deactivating such devices treads the fine line between legitimate withdrawal of burdensome treatment and assisted death. Although the specific deliberations of the DCBC are confidential, this article summarizes contributions from the committee’s discussion, as well as independent research undertaken by the author.
Cardiopulmonary resuscitation is not addressed in the admitting medical records for the majority of patients who undergo CPR in the hospital
Authors: Mirza Ayoub , Kad Rishi , Ellison Neil M.
Published: May 2006

Cardiopulmonary resuscitation (CPR) is routinely performed on patients who develop cardiopulmonary arrest in the hospital. In some situations, it is performed on terminally or critically ill patients where death is predicted to be inevitable despite CPR. Since prior consent is not required for this procedure, CPR may be performed without patient consent or foreknowledge. Many of these patients may not want CPR if the anticipated outcome is reviewed with them.

This study investigated the frequency of occurrence of a CPR discussion at the time of hospital admission for patients who undergo CPR during hospitalization. Results showed that CPR is infrequently addressed in the hospital orders or medical records in patients who undergo CPR during their hospital stay. In addition, the severity of illness at the time of admission does not appear to influence whether physicians discuss CPR with patients and their families.