bluuebunny/crossref_metadata_2025 huggingface dataset:
Relieving the agony of the new pain management standards
Authors: Yadgood Maureen Cirbee , Miller Phyllis J. , Mathews Patricia A.
Published: May 2006

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued new standards for pain assessment in accredited hospitals and other health care settings, including hospice and home care. Under the new pain management standards, health care facilities will be called upon to recognize the right of patients to appropriate assessment and management of pain; to assess the existence of pain, its nature, and intensity; to record the results of the assessment in a way that facilitates regular reassessment and follow-up; to determine and ensure staff competency in pain assessment and management, and to address pain assessment and management in the orientation of all new staff; to establish policies and procedures that support the appropriate prescription or ordering of effective pain medications; to educate patients and their families about effective pain management; and to address patient needs for symptom management in the discharge planning process. Many health care organizations are reporting confusion and lack of understanding about the scope of the new standards. To address this issue, this article summarizes the new pain management standards. This article is based on a three-part series published in the Journal of Healthcare Safety, Compliance & Infection Control (January, March, and April 2000).
A critical pathway for interdisciplinary hospice care
Authors: Wright Patricia Moyle
Published: May 2006

In today’s managed health care environment, many hospices are seeking to streamline care while maintaining quality. Quality hospice care is dependent on communication and planning among members of the interdisciplinary team. A critical pathway can be useful in determining effective interventions in a uniform manner. In order to maintain quality and provide uniform care, a guiding framework is necessary. A critical pathway is presented here and is designed specifically for hospice care. An overview is presented of the usefulness of the critical pathway in the case management model. In theory, the critical pathway can be used as an outline for care to improve quality, maximize effectiveness, and generate further research in hospice practice.
Measuring comfort in caregivers and patients during late end-of-life care
Authors: Novak Beverly , Kolcaba Katharine , Steiner Richard , Dowd Therese
Published: May 2006

The purpose of this study was to test several formats of end-of-life comfort instruments for patients and closely involved caregivers. Kolcaba’s Comfort Theory was the theoretical framework utilized. Different response formats for two end-of-life (EOL) comfort questionnaires (for patients and caregivers, respectively), and horizontal and vertical visual analog scales for total comfort (TC) lines were compared in two phases. Evaluable data were collected from both members of 38 patient-caregiver dyads in each phase. Suitable dyads were recruited from two hospice agencies in northeastern Ohio. Cronbach’s alpha for the EOL comfort questionnaire (six response Likert-type format) tested during phase I for patients was .98 and for caregivers was .97. Test-retest reliability for the vertical TC line tested during phase I for patients was .64 and for caregivers was .79. The implications of this study for nursing practice and research are derived from the American Nursing Association (ANA) position statement about EOL care, which states that comfort is the goal of nursing for this population. These instruments will be useful for assessing comfort in actively dying patients and comfort of their caregivers as well as for developing evidence-based practice for this population.
On the 10th anniversary of the organization of the American Academy of Hospice and Palliative Medicine (AAHPM): The first 10 years
Authors: Holman Gerald H. , Forman Walter B.
Published: May 2006

The American Academy of Hospice and Palliative Medicine (originally chartered as the Academy of Hospice Physicians in 1988) is an organization of physicians devoted to advancing hospice and palliative medicine in the United States. The academy’s mission is “physicians dedicated to promoting quality hospice care for the terminally ill through medical education, research, and training.” The academy obtained specialty recognition from the AMA in 1996 and became the first physicians’ group to publish its position on physician-assisted suicide in 1991 and again in 1997.
The use of transdermal fentanyl in pediatric oncology palliative care
Authors: Noyes Michelle , Irving Helen
Published: May 2006

Transdermal fentanyl offers a noninvasive approach to the management of patients with opioid dependent and stable, chronic cancer pain. The transdermal delivery system offers distinct advantages where oral administration of opioids is difficult as a consequence of progressive disease and in patients whose compliance with oral medications is poor. Thirteen patients ranging in age from three years and nine months to 18 years and seven months were treated with transdermal fentanyl for between six hours and 112 days. All had previously been receiving oral morphine prior to the commencement of fentanyl and were transferred to fentanyl because of oral opioid side effects and poor oral compliance. Fentanyl was well tolerated and provided effective pain relief for 11 of 13 patients. Overall, patients and parents experienced satisfaction with fentanyl, both in terms of pain relief and improvement in quality of life.
Dying at home: Emergency medications for terminal symptoms
Authors: LeGrand Susan B. , Tropiano Pam , Marx Joel D. , Davis Mellar P. , Walsh Declan
Published: May 2006

This article discusses the use of a medication kit at home for terminal symptoms. This innovation has been in place for more than two years at the Hospice of the Cleveland Clinic. There is no previously published information on this innovation in the literature.
Qualitative findings on the experience of end-of-life care for hematological malignancies
Authors: McGrath Pam
Published: May 2006

There is a loud silence in the literature on the issues related to palliative care for hematological malignancies. This article presents information that begins to address that silence. The limited research that is available indicates that, to date, patients with a hematological malignancy and their families received scant attention with regards to the provision of palliative care. The findings presented in this article demonstrates that families are enduring considerable hardship and are left with much emotional pain and many unresolved issues when such care is not offered. It is hoped that the findings presented in this article will be used for developing effective strategies to ensure that patients with hematological malignancies and their families, no less than any others, can be afforded the dignity and respect that the appropriate provision of palliative services ensures.
Redefining hope for the terminally ill
Authors: Parker-Oliver Debra
Published: May 2006

This paper discusses how hospice social workers assist patients and families in finding new hope and meaning in their lives as care goals turn from cure to comfort. Assessment factors important to the redefinition process and intervention strategies are explored. Hope is defined as the positive expectation for meaning attached to life events with the emphasis on meaning instead of life events. The author seeks to demonstrate the importance of meaning to the feeling of hope and the possibility of socially constructing meaning to alleviate the traditional medical perspective that hope revolves around the outcome of disease.
You need not make the journey alone: Overcoming impediments to providing palliative care in a public urban teaching hospital
Authors: Ryan Angèle , Carter Jackie , Lucas Janet , Berger Jack
Published: May 2006

The majority of dying patients continue to receive care in acute, tertiary settings. This has generated the development of hospital-based palliative care (HBPC). The Symptom Management and Palliative Care Program (SMPCP) at LAC+USC Medical Center provides HBPC. The SMPCP operates as an interdisciplinary consultative service, assessing inpatients, and documenting recommendations for primary physicians. Over a 28-month period the SMPCP provided clinical recommendations, education, and research for patients, family members, and hospital staff. Demographic, clinical, psychosocial, financial, and outcome information was collected on 265 patients. The SMPCP documented the attainment of defined quality end-points, including pain control within 24 hours, a Do Not Resuscitate (DNR) discussion with patient and family within 72 hours, and control of nausea and vomiting within 24 hours. Team members also documented impediments to implementing recommendations and the success of interventions to overcome impediments. Results indicated that the SMPCP achieved a high rate of quality end-point attainment when impediments were not present. The most significant impediments resulted from behaviors by primary physicians. The SMPCP’s ability to overcome barrier behaviors improved the rate of end-point attainment, confirming the importance of palliative care at the end of life.
Burnout and compassion fatigue among hospice caregivers
Authors: Keidel Gladys Catkins
Published: May 2006

Burnout is a word currently used in discussions about the present nursing shortage. Hospice staff, because of their work with the terminally ill, are considered a high-risk group for burnout. Too frequently, the reason behind the decision to leave or take a sabbatical from hospice work is that the staff member reached the limits of his or her capacity to care and “couldn’t take it any more.” It is, therefore, important to discuss the concept of burnout and how it can affect hospice staff as well as the primary caregivers for hospice patients to ascertain the reasons behind it and take steps to lessen caregiver stress.
Attitudes toward care of the terminally ill: An educational intervention
Authors: Frommelt Katherine H.Murray
Published: May 2006

This quasiexperimental study examined the effect of an educational program on attitudes toward caring for terminally ill persons and their families. Participants were 115 undergraduate students: intervention group, N = 49; control group, N = 66. Preand post-intervention measurements were done with the Frommelt Attitude Toward Care of the Dying Scale (FATCOD, Form B). Students in the intervention group participated in a semester-long (15-week, 45-hour) educational program. Demographic variables, including age, gender, religion, major area of study, influence of religious beliefs, profession, previous education, and past or present experience with loss were evaluated. Statistical analyses (t-test, ANOVA, ANCOVA, and APVs) indicated a significant positive change in the attitude scores of the intervention group and no significant change in the attitude scores of the control group.
Predictors of six-month survival among patients with dementia: An evaluation of hospice Medicare guidelines
Authors: Schonwetter Ronald S. , Han Beth , Small Brent J. , Martin Brenda , Tope Kimberly , Haley William E.
Published: May 2006

The goal of the present study was to assess the validity of the Medicare hospice eligibility guidelines for dementia patients, as well as identify predictors that could more accurately identify prognosis in dementia patients referred to hospice. A retrospective chart review was conducted, including initial assessment and longitudinal follow-up of patients until the time of death. In addition, a second validation cohort was also followed. Participants consisted of 245 patients admitted to a large community-based hospice with a diagnosis of dementia, including a validation sample of 80 patients. The Kaplan-Meier estimation of survival and a Cox regression analysis (p > 0.05) revealed no significant relationship between the Medicare guidelines or any component of the guidelines and survival at six months for the initial and validation samples. Significant multivariate predictors of shorter survival in both the initial and validation sample include greater age (p = 0.02) and anorexia (p < 0.001), as well as a combination of anorexia and greater functional impairment (p = 0.005). Overall, the results indicated that the Medicare guidelines were not valid predictors of survival in hospice patients with dementia and should be altered to include empirically valid predictors. Advanced age, as well as impaired nutritional and functional status, was associated with shortened survival in these patients. The predictor variables identified are an initial step toward providing improved prognoses for advanced dementia patients, their families, and practitioners. Broader issues in improving access to hospice care for dementia patients are discussed.
Integrating complementary and alternative medicine (CAM) into standard hospice and palliative care
Authors: Lewis Charles R. , de Vedia Ana , Reuer Barbara , Schwan Rodney , Tourin Christina
Published: May 2006

In the United States, there are 629 million visits to complementary and alternative medicine (CAM) providers each year. Many adults appear to value both conventional and CAM approaches. Because of this public interest and promising evidence that CAM relieves suffering and improves quality of life, we established a program of CAM, known as Integrative Palliative Care (IPC), in a US hospice. This paper outlines our strategy of collaborative relationships with community schools of traditional Chinese medicine (TCM), massage, and harp therapy. It also describes the use of volunteers and small grants and donations to develop and maintain a program of CAM in the hospice setting. The difficulties of research design, problems with tracking outcomes, and the shortcomings of providing therapies with this model are discussed.
A syllabus for fellowship education in palliative medicine
Authors: LeGrand Susan B. , Walsh Declan , Nelson Kristine A. , Davis Mellar P.
Published: May 2006

Recent years have seen significant growth in palliative medicine training programs and positions. 1 There are plans to pursue palliative medicine specialty status with the American Board of Medical Specialties and accreditation of fellowship programs with the American College of Graduate Medical Education. A work group of program directors, supported initially by the Cleveland Clinic and then by the American Board of Hospice and Palliative Medicine, has recently published standards for fellowship training. 2 Despite this, fundamental questions remain about defining the field and delineating the knowledge and skills expected following completion of specialty training. In this article, we describe the first fellowship program in palliative medicine (PMP) in the United States, developed and supported by the Cleveland Clinic Foundation. 3 The program has been implemented as part of the Harry R. Horvitz Center for Palliative Medicine, founded in 1987 as the first comprehensive integrated US program in this field. This training program, in existence since 1989, features a traditional rotational structure with an inpatient primary care service, inpatient consult services, and an outpatient consult/hospice service. This article outlines the syllabus developed for this fellowship, given what we believe to be the essential knowledge base for the field of palliative medicine.
Medication-focused approach to total pain: Poor symptom control, polypharmacy, and adverse reactions
Authors: Al-Shahri Mohammad Zafir , Molina Emilio Herrera , Oneschuk Doreen
Published: May 2006

Neuropathic pain, known to have poor opioid response, can be difficult to control. 1-3 Although several classes of adjuvant medications are believed to be of benefit in managing neuropathic pain, they have potential side effects that occasionally outweigh their benefits. 4-7 The psychospiritual suffering of patients with advanced cancer may heighten the distress associated with physical symptoms. 8-10 If undiagnosed, this may lead to increases in dose and the number of medications administered in the hope of better symptom control. This case report describes the successful interdisciplinary management of an advanced cancer patient whose multiple drug therapy had added to rather than alleviated his distress by causing more side effects than symptom relief.
Assessment of nutritional status and fluid deficits in advanced cancer
Authors: Sarhill Nabeel , Mahmoud Fade Aziz , Christie Richard , Tahir Adnan
Published: May 2006

Malnutrition and cachexia are frequent manifestations of cancer and are major contributors to morbidity and mortality. The assessment of nutrition status in cancer patients can be easily accomplished. The first step is to record a complete medical history and to perform a thorough clinical examination to uncover signs of nutritional deficiency. Simple and inexpensive tests are available to assess the body composition, such as: anthropometric measurements, skinfold thickness, arm muscle circumference and area, and weight and body mass index (BMI). Biochemical measurements are also available, such as serum albumin, transferring, and prealbumin.

Fluid deficit is divided into two categories based on pathophysiology (dehydration and volume depletion) and to three subtypes based on plasma sodium concentration (hyponatremic, hypernatremic, and isotonic). Dehydration (total water deficit, especially intracellular) is always hypernatremic, while volume depletion (intravascular water and sodium deficit) is either hyponatremic, hypernatremic, or isotonic. There are no clear clinical differences among the various categories, but a delay of capillary refill, tachycardia, and orthostatic hypotension is more common with volume depletion. Careful clinical assessment and laboratory tests, especially serum sodium, are the keystones for diagnosis and effective management. Bioelectrical impedance (BEI) is an easy way to assess both nutrition status and fluid deficits in advanced cancer and should be used more often than it currently is. This article reviews the subjective and objective methods of assessing fluid deficit and nutrition in advanced cancer.
Sexuality at the end of life
Authors: Stausmire Julie M.
Published: May 2006

There is very little research literature that addresses sexuality at the end of life. Although end-of-life care has become a priority for nursing education, the issue of end-of-life sexuality is not included in the curriculum. Nurses are frequently in a position to establish relationships with couples that encourage a frank discussion and information sharing. As patient advocates, nurses can address end-of-life sexuality issues by taking a sexual history and implementing a general intervention model, such as the PLISSIT. Couples need to be reassured that if they have enjoyed a close sexual relationship, sexual intimacy may continue to be part of their relationship, even at the end of life.
Acute pain in advanced cancer: An opioid dosing strategy and illustration
Authors: Davis Mellar P.
Published: May 2006

Opioid dosing strategies for acute pain differ from strategies for chronic pain management. The basic principles of effective, safe dosing are rapid titration to the onset of analgesia followed by maintenance infusions based upon the titrated dose. This article presents guidelines and case histories for safe and effective dosing.
Practical recommendations for ethnically and racially sensitive hospice services
Authors: Lyke Jennifer , Colón Merydawilda
Published: May 2006

Hospice providers have long understood that hospice services are disproportionately utilized by Caucasians compared with racial and ethnic minorities. In fact, it is clear that this disparity is increasing with time 1 despite the development of literature that recommends making services more culturally sensitive and accessible to minority groups. This suggests a need for more concrete and practical recommendations to make hospice services accessible and amenable to minority groups. For implementation in hospice service organizations, standard recommendations require enhancement to increase outreach, improve understanding of cultural issues related to death and dying, improve communication with non-English speaking populations, and implement cross-cultural training programs. In addition, the self-awareness and ethnic identity of hospice workers themselves are elements of culturally sensitive care that frequently are overlooked when discussing hospice organizations. This article outlines some specific objectives for meeting the goal of improving hospice services for ethnic and racial minorities.
Changes in endocrine therapy: Anastrozole and advanced breast cancer in postmenopausal women
Authors: Nabholtz Jean-Marc
Published: May 2006

Emerging data on endocrine therapies necessitates a re-evaluation of treatment strategies for advanced breast cancer. In this review, we present data from recent studies of the third-generation, nonsteroidal aromatase inhibitor (AI) anastrozole that illustrate its changing role in the treatment of postmenopausual women with advanced breast cancer. These studies demonstrate that anastrozole is now a treatment of choice as first-line therapy for patients presenting with advanced breast cancer and for patients who have progressed to advanced disease after adjuvant therapy with tamoxifen. A further trial has also shown that anastrozole is an effective and well-tolerated alternative to tamoxifen as adjuvant treatment for postmenopausal women with early breast cancer.
Validation of the Caregiving at Life’s End questionnaire
Authors: Salmon Jennifer R. , Kwak Jung , Acquaviva Kimberly D. , Egan Kathleen A. , Brandt Katherine
Published: May 2006

The researchers in this study developed and validated a questionnaire to measure the needs of end-of-life (EOL) caregivers. The model is used to facilitate meaningful and supportive experiences for both the patient and caregiver. The questionnaire was developed using existing scales of meaning, self-acceptance, burden, and gain as well as new scales of caregiver comfort, importance of caregiving tasks, and caregiver closure. The sample included 34 current and 17 bereaved caregivers affiliated with The Hospice Institute of the Florida Suncoast. The scales performed well in terms of concurrent validity, internal consistency, and reliability.
Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents
Authors: von Gunten Charles F. , Twaddle Martha , Preodor Michael , Neely Kathy Johnson , Martinez Jeanne , Lyons John
Published: May 2006

There is compelling evidence that residents training in primary care need education in palliative care. Evidence for effective curricula is needed. The objective of this study was to test whether a clinical elective improves measures of knowledge and skill. Residents from three categorical training programs in internal medicine were recruited to an elective including clinical experiences in an acute hospital palliative care consultation service, on an acute hospice and palliative care unit, and in-home hospice care. A 25-question pre- and post-test and a videotaped interview with a standardized patient were used to assess communication skills and measure outcomes. Residents demonstrated a 10 percent improvement in knowledge after the four-week elective (p < 0.05). All residents demonstrated basic competency in communication skills at the end of the rotation. These results indicate that clinical rotation shows promise as an educational intervention to improve palliative care knowledge and skills in primary care residents. An important limitation of the study is that it is an elective; further studies with a required rotation and/or a control group are needed to confirm the findings.
Terminal restlessness as perceived by hospice professionals
Authors: Head Barbara , Faul Annatje
Published: May 2006

Any hospice professional can identify the syndrome known as terminal restlessness, and all would agree that it is extremely distressing to patients as well as their families and care-givers. Often, caregivers cannot ameliorate the anguish many patients experience at life’s end. Many clinicians assert that the causes are physical resulting from medication toxicity, organ shutdown and the associated metabolic changes, pain, urinary or fecal retention, dyspnea and related hypoxia, and sepsis. Yet, many also credit psychosocial and spiritual distress as precipitating factors.

The purposes of this study were twofold: to compare the perceptions of practicing hospice clinicians with the literature related to terminal restlessness, and to determine if their experience with terminal restlessness agreed with the components of the one established scale for terminal restlessness found in the literature.

In general, the study findings corresponded to the literature in regards to frequency, definition, causes, and behavioral manifestations of terminal restlessness. The clinicians in the study supported the impact of psychosocial and spiritual causes of terminal restlessness and defined the phenomenon in terms of time period; emotional, physical, and spiritual distress; changes in consciousness; and increased activity. However, the study did not support the inclusion of impaired consciousness and withdrawal as comprised in the terminal restlessness scale.
Ziconotide: Can we use it in palliative care?
Authors: Prommer Eric E.
Published: May 2006

Ziconotide (PRIALT ® ) is a new nonopioid treatment for chronic pain. It is a peptide that is the synthetic analog of the omega-conotoxin, derived from the marine snail, Conus magus. The therapeutic benefit of ziconotide derives from its potent and selective blockade of neuronal N-type voltage-sensitive calcium channels. Interference with these channels inhibits input from pain-sensing primary nociceptors. A recent clinical trial demonstrated that ziconotide has a significant analgesic effect compared to placebo in patients considered intolerant or refractory to other treatment such as systemic analgesics, adjunctive therapies, or intrathecal (IT) morphine. Thus, ziconotide is the first of a new class of agents—N-type calcium channel blockers, or NCCBs. Ziconotide may represent another option for patients with refractory pain.
Bisphosphonate-induced hypocalcemia associated with vitamin D deficiency in a patient with advanced cancer
Authors: Broadbent Andrew , Glare Paul , Crawford Bronwyn
Published: May 2006

A case is presented of symptomatic hypocalcemia following treatment with bisphosphonates. This patient also had deficiency of 25 hydroxyvitamin D that was unrecognized. The use of bisphosphonates in cancer is increasing, not only in the treatment of hypercalcemia, but also for bone pain and to decrease the risk of skeletal morbidity in metastatic breast cancer, multiple myeloma, and Paget’s disease in normocalcemic patients. The patient was probably vitamin D deficient because of a combination of poor oral intake, inadequate sunlight exposure, and the development of renal failure. However, despite receiving both parenteral and oral calcium therapy, the serum calcium remained low until the replacement of vitamin D. With increasing use of bisphosphonate therapy in malignant disease, we believe that an assessment of vitamin D status, calcium intake, renal function, phosphate, magnesium, and albumin should be undertaken prior to initiating therapy in most palliative care patients.
Use of methylphenidate in patients with cancer
Authors: Sood Amit , Barton Debra L. , Loprinzi Charles L.
Published: May 2006

Cancer and its treatment are often associated with symptoms such as depression, somnolence, cognitive abnormalities, and fatigue. Methylphenidate, a stimulant medication, is commonly used to treat these symptoms. Several small pilot and a few adequately powered studies have assessed the safety and efficacy of methylphenidate in patients with cancer. Overall, the studies so far suggest that methylphenidate is well-tolerated in patients with cancer. Further, the studies have provided initial evidence of efficacy of this agent in patients with cancer. The present article reviews the evidence base behind the use of methylphenidate in these patients.
Spiritual caregiving
Authors: Owen-Still Sally
Published: May 2006

If I were asked for the single most striking insight into human nature and the human condition, it would be this; that no person is strong enough to support the meaning of his or her life unaided by something and/or someone outside himself or herself.
An experience in listening
Authors: Hay Jean
Published: May 2006

This article was written in memory of Jacqueline Genest. This article was written in memory of Jacqueline Genest.
A study of hospice costs for non-Medicare age group Results show significant savings during last month of life
Authors: Narkiewicz Robert D.
Published: May 2006

Thepurposeofthis study is to examinethe complete costs of hospice care for a non-Medicare age population. The hospice programs selected were part of the Blue Cross and Blue Shield of Massachusetts hospice demonstrationproject. The direct costs of hospice and conventional care for the terminally ill were assessed, by month, forthe last six months oflife. Thestudy format indicates the effects hospice stay, as an independent variable, had on comparative costs between two population samples. Results showed that hospice care was associated with significant savings in the lastmonth of life, but was somewhat more costly in months prior to this period. Finally, savings attributed to the last month of life were significantly large to offset losses in the prior months.
Suicide and the Hospice Patient
Authors: Kliban Marcia G.
Published: May 2006

Articles about euthanasia and rational suicide intrude almost weekly upon the general and professional public, as frustrated family and professional caregivers make right-to-die decisions for patients and implement them unilaterally. One cannot assume that these issues would disappear if there were greater hospice involvement and support for those patients and families. However, one can accept responsibility for the quality of care provided and offer guidelines for the staff directly giving care. This paper describes the guidelines developed by one hospice for working with patients who express a suicide wish or attempt suicide.
A specialized hospice for dementia patients and their families
Authors: Brechling Brigid G. , Kuhn Dan
Published: May 2006

This article reports the development of a small pilot program and briefly describes its activities.

The growing number of dementia patients in American communities indicates a need to extend hospice services to these patients and their families. It is difficult to determine at present whether this need could be met more effectively by encouraging existing hospices to accept these patients or by establishing specialized programs such as this one. Research in this area is indicated, as well as the sharing of information among hospices providing care to other specialized groups — people with AIDS or terminally ill children for example.

The Alzheimer's Family Care Hospice has provided services to eight terminally ill dementia patients and their families in a pilot project sponsored jointly by the Rush Alzheimer's Disease Center and the Chicago Area Chapter of the Alzheimer's Association. Another six patients did not meet admission criteria.
A creative approach to a small town hospice
Authors: Hare Jan , Koepke Leslie
Published: May 2006

This paper describes a relatively new hospice program in which the primary resources are cooperatively provided by a rural community hospital and a university family social science department. Though the program is in its infancy and is in need of much refinement, the benefits derivedfrom its unique structure are worthy of examination. Furthermore, other hospices may want to consider the advantages of involvement with universities in terms of academic programming, service and research potential.
Confusion in the terminally ill: Recognition and management
Authors: Martin Edward W.
Published: May 2006

Pain has been managed aggressively by hospice programs. However, other problems, particularly neuropsychiatric problems, such as confusion, can go unrecognized and untreated even in a hospice setting. The resulting disturbing, violentor disruptive behavior will severely detract from the quality of life the patient and family can share together. Dementia and delirium can be diagnosed using a mental status exam. Care-givers can then be be informed about the special needs of the patients and prepared for potential problems. Identification of reversible causes for delirium can continue while agitated behavior is managed with behavioral and pharmacologic approaches. Confusion is a common problem in the terminally ill and prompt recognition and management of the potentially disruptive symptom can do a great deal to maximize the quality of the patient's life.
Training physicians to care for the dying
Authors: Bulkin Wilma , Lukashok Herbert
Published: May 2006

Problem:

The education of medical students and house staffre garding management of death and timely discussions of death with patients and families has been deficient, leaving physicians ill equipped to provide appropriate care to dying patients.

Method:

We propose a five-pronged curriculum in terminal care to be ongoing frommedicalschool through postgraduate training. Thisprogram includes:

• Clinical skill' — including pain and symptom management, prognostication and care in various settings;

• Communication skills — including listening and how to discuss bad news withpatient andfamily;

• Psychosocial issues;

• Administrative/management and team interaction, and

• Bioethical issues, including DNR and living wills.

Conclusion:

It is hoped that such training will teach physicians to accept death as inevitable, to recognize and acknowledge the state ofdying and,flnally, to understand that appropriate care includes appropriate death, which isone arrived at with minimal suffering, with minimal social and emotional impoverishment, with preservation or restoration of important relationships and with resolution of residual conflicts.
Training our future physicians: A hospice rotation for medical students
Authors: Knight Carol F. , Knight Peter F. , Gellula Mark H. , Holman Gerald H.
Published: May 2006

A required 16 hour hospice clinical rotation was developed as part of a medical student family practice clerkship. The effect of the hospice rotation on student beliefs and attitudes towards the care of dying patients was measured by pre and post-test questionnaires using a Likert scale. Sixty-five completed pre and post-tests were analyzed using a paired t-test. It was determined that there were statistically significant changes in responses to 15 of 23 items. The rotation positively q1 fected student attitudes about hospice care, student attitudes about a hospice rotation, and beliefs concerning palliative care.

The authors believe that qualified hospice programs can, and should, serve an active role in teaching medical students about the physical and psychosocial aspects of caring for the dying.
The effect of the Medicare regulations on hospice practice: Enhancing staff performance
Authors: Tierney Jeanette , Wilson Damien
Published: May 2006

The purpose of this paper is to examine the federal hospice regulations (42 CFR 418.50 - .100) and identify from these standards key characteristics that help define important aspects of palliative hospice care. The other purpose will be to examine these requirements to determine what these standards say or imply about the functioning of the hospice staff within the certified program.

We assert that in order for a certified program to function in the capacity outlined in the federal hospice requirements, both the administration and staff need to understand, and then practice, the complex role delineated within the Congressional Law and ensuing regulations.

The Medicare hospice regulations are a recognized program standard throughout the nation. These requirements, finalized in 1983, were developed by the Health Care Financing Administration (HCFA) as a result of the Congressional Tax Equity and Fiscal Responsibility Act (TEFRA, 1982).1 Since the promulgation of these regulations, hospices wishing to gain certification have had to adapt and mold their program focus and clinical procedures to meet this legislative mandate.

Although some hospice administrators may perceive the Medicare requirements simply as hoops to be jumped through in order to gain funding, in truth, these regulations stand as a benchmark in the history of American hospice care. In their totality, the rules set forth a system of health care that is singular in program design.
Effective hospice volunteers: Demographic and personality characteristics
Authors: Caidwell Jackie , Scott Jean Pearson
Published: May 2006

The purpose of the study was to examine demographic and personality characteristics of highly effective hospice volunteers. Volunteer coordinators of all Texas Hospice Organization member hospices were asked to select their most committed and effective volunteers to participate in the study. Volunteers had above-average incomes, were predominately white, female, active in other voluntary activities, and motivated by their own experiences with death of a loved one. The largest proportion of female volunteers (27.3 percent) were extroverted, sensing, feeling, judging personality types (ESFJ), whereas, for male volunteers, the largest proportion (20.8 percent) were introverted, sensing, thinking, judging personality types (ISTJ). This information will be beneficial in recruitment, training, and retention of hospice volunteers.
The effect of intravenous fluid infusion on blood and urine parameters of hydration and on state of consciousness in terminal cancer patients
Authors: Wailer Alex , Hershkowitz Moshe , Adunsky Abraham
Published: May 2006

The purpose of the present study was to assess retrospectively the state of hydration of terminal cancer patients in the last 48 hours of their lives, with or without IV fluid infusion and to correlate parameters of hydration with the state of consciousness (SOC). We studied the parameters of hydration in plasma and urine of68 consecutive patients 48 hours or less before death. Thirteen patients were treated by IV fluids. We found a state of dehydration in all investigated patients as reflected by biochemical parameters. Patients with IV fluids were not better hydrated and did not show better SOC. SOC correlated significantly with plasma sodium (p < 0.001) and urine osmolality (p < 0.02). In light of the present findings, the decision-making process regarding treatment with IV fluids should be guided by the preferences of the dying patient and his family.
Splenic irradiation in the palliation of patients with lymphoproliferative and myeloproliferative disorders
Authors: Paulino Arnold C. , Reddy Sarada P.
Published: May 2006

Introduction: Splenic irradiation is an accepted mode of treatment for palliation of hypersplenism and splenic pain for patients with lymphoproliferative or myeloproliferative disorders. However, results are conflicting regarding the duration of palliation and the toxicity associated with this treatment.

Methods: Twenty-five patients with lymphoproliferative or myeloproliferative disorders were treated with splenic irradiation for palliation of splenomegaly and pain. The spleen was measured and pain and toxicity were assessed during radiation therapy.

Results: Splenomegaly and splenic pain decreased in 60 percent and 91 percent of patients, respectively. Radiation doses higher than 500 cGy appeared to be more effective than lower doses in reducing the spleen size in patients with chronic lymphocytic leukemia. Regression of splenomegaly and pain relief were maintained for less than one year and more than six months, respectively. Acute radiation toxicity resulted in the cessation of radiotherapy in two patients.

Conclusion: Splenic irradiation is effective in the short-term palliation of splenomegaly and pain and may be most useful in the subset of patients with a life expectancy of less than one year. Terminally ill patients with splenomegaly secondary to lymphoproliferative or myeloproliferative disorders may benefit from splenic irradiation to minimize pain and pressure symptoms in addition to possible reduction of narcotic use.
Cross-cultural training for nurses: A research-based education project
Authors: Flavin Charlotte
Published: May 2006

Of 100,374 persons living in Maui County, Hawaii, 58 percent are Asians and Pacific Islanders, and 39 percent are Caucasians. By contrast, a visual survey of the nursing staff of two home care agencies showed approximately 85 percent Caucasians and 15 percent People of Color. A research-based, Cross-Cultural Training (CCT) was conducted to educate home care nurses about the beliefs, values, and practices regarding illness and dying among the Filipino, Hawaiian, Japanese, and gay-Caucasian communities. The training protocol adapted the cultural assimilator and behavior modeling methods utilized in Harrison’s 1992 study with the addition of a panel presentation by ethnic and cultural experts. Pre- and post-test measures of the combined approach yielded positive results in reactions and behavioral skills, although learning results were not statistically significant.
Spiritual diversity: A challenge for hospice chaplains
Authors: Hall Scott E.
Published: May 2006

Spirituality is a critical component of the holistic mind-body-spirit model embraced by Hospice. Hospice chaplains, as part of the caregiving team, must understand their abilities and limitations in providing spiritual guidance to others who may differ in religious and spiritual beliefs.
Part two: Breast cancer, colorectal cancer, and esophageal cancer
Authors: Kemp Charles
Published: May 2006

This is the second of a six-part series on metastatic spread and natural history of 18 common tumors. Part one summarized symptom/problem anticipation, cancer metastasis, and the 18 tumors that each cause more than 6,000 deaths per year in the United States. Bladder and brain cancer were discussed, with information given on tumor types, metastatic spread and invasion, and common symptoms.

Part two charts the natural histories of breast, colorectal, and esophageal cancers. Each of these cancers is presented separately, with information given on mortality rates, the most common tumor types, sites of metastases, common problems, and common oncologic emergencies. Sites of spread, resulting problems (including site-specific symptoms), and assessment parameters are presented as tables. Material is presented so that clinicians will be able to anticipate the spread of these cancers and thus identify problems early in their development so that the problems are more easily managed.
Viatical settlements: Ethical perspectives
Authors: Greipp Mary Elizabeth
Published: May 2006

Viatical settlements are new within the last decade. A settlement contract is a written agreement between a viator (terminally ill person) and an independent viatical settlement company. The company purchases the viator’s life insurance policy before the person expires, paying a designated percentage of the policy’s worth in exchange for ownership of the policy and beneficiary rights. The viatical settlement company assumes the responsibility for paying the premiums on the policy until the death of the viator. Settlement or proceeds to the viator typically average between 50 and 80 percent of the face value of the policy. This article examines the ethical ramifications of viatical settlements.
Perceptions and decision-making on rehydration of terminally ill cancer patients and family members
Authors: Morita Tatsuya , Tsunoda Junichi , Inoue Satoshi , Chihara Satoshi
Published: May 2006

Although the appropriateness of forced rehydration for terminally ill cancer patients has been actively discussed, few studies have investigated its psychological aspects. To clarify patients’ and family members’ perceptions about rehydration and identify contributing factors for decision-making, a prospective structured survey was performed on 121 hospice inpatients with insufficient oral intake.

Physicians did not recommend rehydration in 78 percent of patients, and 75 percent decided not to receive artificial fluid therapy. Various concerns affected decision-making: 76 percent of patients and 85 percent of family members believed patients could not get appropriate nutrition without artificial rehydration. Some 56 percent of patients and 84 percent of family members said that withholding rehydration would cause premature death, while more than half agreed that forced rehydration might worsen the patients’ suffering.

Patients’ performance status, fluid retention signs, denial, physicians’ recommendations, patients’ and family members’ beliefs about the effect of hydration on patients’ distress, and family members’ anxiety about withholding rehydration were significantly associated with decision-making. Multiple regression analyses revealed patients’ denial, physicians’ recommendations determined by patients’ performance status and fluid retention symptoms, and family members’ belief that rehydration could worsen patients’ distress as independent determinants for rehydration.

In conclusion, hospice care receivers had various concerns about rehydration, related to patients’ nutrition, survival, and distress. The main determinants for rehydration therapy were patients’ performance status, fluid retention symptoms, denial, and care receivers’ beliefs about the effect of hydration on the patients’ distress.
Symptom management algorithms for palliative care
Authors: Wrede-Seaman Linda
Published: May 2006

In order to develop standards of care that alleviate pain and other distressing symptoms among dying patients, the Providence Hospice of Yakima team has developed and utilized pain and nonpain symptom management algorithms. In use since late 1993, the system is a success, as demonstrated by positive satisfaction surveys among physicians, staff, and family members. This article offers an introduction to the algorithmic process, key components of its success, and guidelines for further improvement in the care provided to dying patients.
Hypnosis: Useful, neglected, available
Authors: Douglas Donald B.
Published: May 2006

Hypnosis is presented as a valuable and frequently neglected resource for many patients with chronic and terminal illness. Particular attention is given herein to the use of hypnosis in attaining relaxation, overcoming insomnia, helping the patient achieve pain relief, and, most particularly, teaching the patient to work with relatives and other persons close to them, as caregivers in a special relationship that can be a very important source of relief to the patient. A brief overview of indications, contraindications, errors, and safeguards is given. Sources of education and training are briefly reviewed and a bibliography is included to identify the nature of professional societies, three in the United States and one international, together with some standard publications. The purpose of this article is to affirm the value of hypnosis as a complementary or alternative therapy for hospice patients, to summarize its clinical applications, and to list the most standard and best known professional societies and publications.