bluuebunny/crossref_metadata_2025_split huggingface dataset:
Barriers, challenges, and opportunities related to the provision of hospice care in assisted-living communities
Authors: Dixon Sharon , Fortner Janet , Travis Shirley S. 
Published: May 2006

The purpose of this project was to clarify the barriers, challenges, and opportunities associated with providing care to older adults residing in assisted-living communities. Three focus groups (hospice team members, family members of individuals who received hospice care while in assisted living, and administrators of assisted-living communities) were convened to discuss hospice care. Thematic analysis of the transcribed focus group tapes was used by the authors to identify the common and unique barriers, challenges, and opportunities identified by each group. All three groups were overwhelmingly in support of the right of residents in assisted-living communities to live and die in place, without being transferred to nursing homes or other acute-care facilities, and of the role that hospice plays in enabling residents to achieve that goal. The three groups also agreed that trends in the development of assisted-living communities create difficulties for the industry, confusion for consumers, and the need for increased accountability by providers. Delivering hospice care to places where consumers want to live and die in place will be a complex task. Among other things, traditional hospice care is not easily transported into the social models of care characterized by assisted-living environments. Changes in hospice organization policies and procedures will be necessary, as will broader, industry-wide reforms in areas such as recruitment, retention of qualified staff, and consistent quality-of-care standards.
Beyond principles: Virtue ethics in hospice and palliative care
Authors: Giblin Marie J. 
Published: May 2006

Living ethically in the face of death is a major challenge for the ill person, the family, and the hospice staff. Beyond the recognized need for ethical decision-making regarding medical principles, there are decisions about character for all involved: “What kind of person will I be?” “What kind of family will we be?” “What kind of caregiver will I be?” “What kind of community will we be?” This article is a discussion of virtues that are appropriate in hospice staff and volunteers: compassion/empathy, faithfulness, justice/advocacy, and practical wisdom. The author calls for a wider sharing of their knowledge and experience.
Palliative medicine in a United States cancer center: A prospective study
Authors: Cowan John D. , Walsh Declan , Homsi Jade 
Published: May 2006

Purpose: (a) To report the medical complexity of cancer and noncancer patients receiving palliative medicine (PM) consultation at a tertiary medical center and (b) to describe the consult recommendations made for this group. Patients and methods: Prospective data collection was performed on all consultations (cancer, n = 175; non-cancer, n = 35) done by first author (JDC) as a PM fellow at the Cleveland Clinic Foundation between July 1998 and April 1999. A computer database was used to query for demographics, complexity of medical problems, current medications, mortality, symptoms, nursing problems, and consult recommendations. Results: A median of three (range, 0-12) acute medical problems and three (range, 0-16) chronic medical problems were identified for each patient. Patients were taking a median of six medications (range, 0-20). They had a median of five symptoms (range, 0-13) with pain (73 percent) being most common, followed by weakness (40 percent) and shortness of breath (40 percent). Cancer patients were twice as likely to have more than five symptoms (48 percent versus 23 percent) (chi-square = 0.006). The most common nursing problems were ambulation or fall risk (15 percent) and skin integrity (11 percent). A median of five (range, 1-11) management recommendations were made as part of each consultation. These included medication changes in 81 percent, nonmedication changes in 53 percent, and follow-up services in 100 percent. The median survival from the time of consultation for the known dead was 29 days with 65 percent living more than 14 days. Conclusion: Multiple recommendations were made with most patients surviving long enough potentially to benefit. Consultation in palliative medicine is a sophisticated intervention involving considerable acuity and complexity of care.
Gastrointestinal symptoms among inpatients with advanced cancer
Authors: Komurcu Seref , Nelson Kristine A. , Walsh Declan , Ford Rashawn Bradley , Rybicki Lisa A. 
Published: May 2006

Nearly one-half of the most frequently reported and most distressing symptoms in patients with advanced cancer are gastrointestinal in nature. This prospective study was designed to assess the frequency of gastrointestinal symptoms among inpatients admitted to a palliative medicine program with advanced cancer. Twenty-nine men and 21 women, with a median age of 64 years (range, 35-84), were interviewed about 17 gastrointestinal symptoms. Age, gender, diagnosis, and medication use were also recorded. The most common diagnoses were cancers of the lung (n = 14), breast (n = 6), and prostate (n = 4). Dry mouth (84 percent), weight loss (76 percent), early satiety (71 percent), taste change (60 percent), constipation (58 percent), anorexia (56 percent), bloating (50 percent), nausea (48 percent), abdominal pain (42 percent), and vomiting (34 percent) were the 10 most common gastrointestinal symptoms. Women had more gastrointestinal symptoms than men (median 8 vs. 6, p = 0.018), although this finding was not statistically significant (p = 0.11) after excluding gender-specific cancers. Women had more taste change and diarrhea than men after excluding gender-specific cancers (p = 0.036 and p = 0.046, respectively). Those with primary gastrointestinal cancers (n = 8) had more indigestion and hiccups than those with nongastrointestinal cancers (n = 39). There was no age difference in symptomatology. The drugs prescribed most commonly were opioids (n = 40), laxatives (n = 38), H 2 blockers (n = 29), appetite stimulants (n = 29), and antiemetics (n = 29). Findings support that gastrointestinal symptoms are very common in hospitalized patients with advanced cancer and that the frequency and type of symptoms differ with gender and gastrointestinal vs. nongastrointestinal primary site.
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.
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.
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.
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.
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.