Nursefriendly.com: End of Life Care

Showing posts with label End of Life Care. Show all posts

Sunday, February 20, 2011

The care was futile, and the patient's wishes, KevinMD.com

by Jim deMaine, MD
“We have a patient on a ventilator here who is stable enough to transfer to your ICU, if that’s OK with you.”
This call, coming from the transfer coordinator, is emblematic of an insurance generated “medical care” coverage issue. I am salaried under the patient’s insurance carrier so the insurer wants this patient back under its wing as soon as possible.
The community hospital has been keeping Stella Norris (not her real name), an 89 year old woman, as long as possible. She is incapacitated from a massive stroke suffered five years ago. There is a feeding tube inserted through the stomach wall and she has needed total body care. 911 was called when she stopped breathing and she was taken to the closest hospital.

via kevinmd.com

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Sunday, February 6, 2011

Hospice Under Medicare | Accepting Hospice Under Medicare | Caring.com

Hospice is a type of care that focuses on relieving pain and other suffering for patients nearing the end of life. To qualify for Medicare-covered hospice care, a patient's treating physician must certify that the patient's illness is likely to be terminal within six months. Once hospice care is begun, there's no more medical treatment for the terminal illness itself.
Given this requirement of a prognosis of only six months to live, and the ending of treatment for the terminal disease, many people resist hospice because it seems like "choosing to die." Many people also fear hospice because they believe that all medical care will end. For several reasons, though, neither one of these fears should stop someone from choosing hospice care.
In the first place, the decision to choose hospice isn't final. If a patient's condition stabilizes or improves, he or she can give up hospice and return to regular Medicare coverage. All it takes is to have a change of mind about giving up treatment, or a doctor's advice to try a new treatment. Or for some reason the patient might not like hospice care and prefer to return to regular Medicare coverage. Patients don't have to give Medicare or the hospice provider a reason -- they can end hospice and return to regular Medicare coverage at any time.

via caring.com

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Tuesday, January 18, 2011

Don't Put Off Talking About The Inevitable: Care At Life's End : Shots - Health News Blog : NPR

With no end in sight to the controversy about whether doctors should be paid to discuss end-of-life options with patients, we thought now was as good a time as any to review the possibilities for care before you die.

Only about a quarter of adults have advance directives in place. The term refers to two types of documents: a living will that instructs people what medical measures to take, if any, to prolong your life, and a health care power of attorney that designates someone to make medical decisions for you if you can't. States call these documents by different names, but their functions are similar.

On the relatively infrequent occasions when people do sign advance directive documents, they're usually thinking about what they would want in a crisis: a heart attack, say, or routine surgery that goes terribly wrong. Most of us don't think about the long, slow decline that may occur with Alzheimer’s disease, for example, that robs people just as surely of their ability to make choices as a medical emergency.

via npr.org

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Wednesday, January 5, 2011

Helping patients experience death, PhillyBurbs.com:

A handful of local hospitals recently started volunteer programs that train ordinary people to sit with those who are alone and dying.

Angelo DeLorenzo spends many nights watching people as they die.

Occasionally, the person wants to talk, sometimes through the night. Often, the patient is unconscious, but DeLorenzo reads to him or her, plays the harp or sits quietly and prays.

Everyone deserves a good death, DeLorenzo believes. No one should die without someone there to hold a hand, whisper reassuring words and make sure the person is comfortable.

So DeLorenzo stays with these dying patients at St. Mary Medical Center, where he frequently takes the overnight shift. The Middletown hospital is one of a handful in the area that have started end-of-life programs, where ordinary people such as DeLorenzo, a chaplain intern, are trained to provide comfort care for people who have no close family available.

"No One Dies Alone" - the name of the program at St. Mary - originated at an Oregon hospital in 2001. It has since spread around the world. More than 1,100 hospitals and hospices have requested copies of the program's manual, said Carleen McCornack, coordinator of the mission center of Sacred Heart Medical Center in Eugene, where the program started.

via phillyburbs.com

These types of programs will go along way towards easing patients and family members into accepting the death of a loved one.

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I'll Never Ration. Not Me. Not I. - NYTimes.com

Opposition to health-care rationing is a little like opposition to growing up. It sounds great. It’s just not very practical.

A society’s resources are always limited. So we have to make choices about what we can afford and what we can’t. Not everyone can afford to own a vacation home — which means vacation homes are rationed. Not everyone can afford to live in towns with excellent public schools — which means that good public education is rationed.

Similarly, we can’t afford to try every feasible medical treatment on every patient. Instead, we make choices. The most obvious form of rationing is the millions of Americans who lack health insurance today. Most of them get less medical care than they need and, in the process, keep down the nation’s total medical bill.

But even those with health insurance experience rationing. How? In many ways.

This country has not spent the money to install computerized medical records, and we suffer more medical errors than many other countries. We underpay primary care doctors, relative to specialists, and we’re left stewing in waiting rooms while our primary-care doctors try to see as many patients as possible. Specialists are usually not paid for time they spend collaborating with doctors in other specialties, and many hard-to-diagnose conditions go untreated. Nurses are usually not paid to counsel people on how to improve their diets or remember to take their pills, and manageable cases of diabetes and heart disease become fatal.

via economix.blogs.nytimes.com

At some point we'll need to accept the fact that we cannot all have every test, every operation, every treatment, every new medicine or see every specialist.

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Saturday, January 1, 2011

Discussing cancer treatment with the terminal patient, KevinMD.com

“Are you giving up on me?” My patient looks at me severely. “There must be other treatment options! Aren’t there some experimental drugs out there? I have beaten this cancer twice before. Are you saying that I can’t beat it again?”
No one can ever know with absolute certainty whether my patient’s newly recurrent cancer might miraculously disappear with one more treatment. His recurrence, however, has developed very quickly and is growing very rapidly. New cancer nodules are developing weekly. I have never seen a patient with a cancer this aggressive have a meaningful, sustained response to further treatment. The research literature confirms my impression.
It is always difficult to know what to recommend. Although “no further treatment” is always an alternative, I routinely run through all of the options, reviewing whatever is available, and hoping that we land on the combination that offers that improbable, one-in-a-thousand cure. However unlikely, we sometimes set up appointments and hope for the best.
Today, though, my sense is that it is time to focus on new goals.
The decision not to pursue more studies and more treatment can be very, very difficult. Surgeon and journalist Atul Gawande in an essay in The New Yorker entitled “Letting Go,” writes about how difficult it can be for physicians and patients to halt cancer treatment as the end of life draws near. The dilemma, he concludes, “arises from a still unresolved argument about what the function of medicine really is — what, in other words, we should and should not be paying for doctors to do.” In Gawande’s view, the profession should equip and supply doctors and nurses “who are willing to have the hard discussions and say what they have seen …”

via kevinmd.com

Article continues at KevinMD.com
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Sunday, December 19, 2010

Death in a hospital is not always comfortable, KevinMD.com

In America, too many people die in the hospital.
I don’t mean that they die due to medical error or incompetence, though that’s always a hot topic of discussion amongst doctors, researchers, administrators, and regulators.
What I mean is that if you ask most people, they say they’d rather die at home, surrounded by their loved ones, drifting off to sleep painlessly after having had last rites administered (feel free to plug in your religious/atheistic ritual of choice here).
Why, then, do so many who want this type of death instead die medically, here in the hospital, undergoing painful treatment and the deprivations and degradations of medical care?
The answer has both simple and complex aspects. But I’ll start by sharing something that most medical professionals believe:
When my time comes, the last place I want to be is in the hospital. Don’t get me wrong–I like GlassHospital–it’s a good place to work, teach, and learn. But when the grim reaper is calling my name, I want to be as far away from here as I can.
No IVs. No needle sticks to test my blood. No waking me up to check vital signs every shift. No hospital food. No fluorescent lights.
No feeding tubes; no bladder catheters (ouch!); for Heaven’s sake, no breathing machines (‘mechanical ventilators’).

via kevinmd.com

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The cost of keeping the terminally ill alive, KevinMD.com

Last year, Medicare paid $55 billion just for doctor and hospital bills during the last two months of patients’ lives.
And it has been estimated that 20 to 30 percent of these medical expenses may have had no meaningful impact. Most of the bills are paid for by the federal government with few or no questions asked. This statistic is from a 60 Minutes story on “The Cost of Dying” and is one reason our healthcare system is in trouble.
Modern medicine has become so good at keeping the terminally ill alive by treating the complications of underlying disease that the inevitable process of dying has become much harder and is often prolonged unnecessarily. The way we set up the system right now, primary care physicians don’t have time to spend an hour with you, see how you respond, if they wanted to adjust your medication. So, the easiest thing for everybody up the stream is to admit you to the hospital. And once someone is admitted to the hospital they’re likely to be seen by a dozen or more specialists who will conduct all kinds of tests, whether they’re absolutely essential or not

via kevinmd.com

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Wednesday, December 15, 2010

Cancer patients die too often in hospitals, study says - The Boston Globe

Researchers at the Dartmouth Atlas Project in Lebanon, N.H., analyzed the records of 235,821 Medicare patients ages 65 and older who died between 2003 and 2007. Overall, the researchers found that one-third of patients spent their last days in hospitals and intensive-care units. But there was a big range. At one end was Manhattan, where 46.7 percent died in the hospital. In contrast, 7 percent of cancer patients died in the hospital in Mason City, Iowa.
While chemotherapy and other aggressive procedures can prolong life and enable some cancer patients to return home and to work, studies have shown that these treatments have little or no value for frail elderly patients and those with advanced cancer. But 6 percent of patients received chemotherapy in their last two weeks of life, and the rate was much higher — more than 10 percent — in some places, the researchers found.
Similarly, more than 18 percent of cancer patients were placed on a feeding tube or received cardiopulmonary resuscitation in their last two weeks of life in Manhattan, compared with less than 4 percent in Minneapolis.

via boston.com

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Sunday, February 20, 2011

The care was futile, and the patient's wishes, KevinMD.com

Sunday, February 6, 2011

Hospice Under Medicare | Accepting Hospice Under Medicare | Caring.com

Tuesday, January 18, 2011

Don't Put Off Talking About The Inevitable: Care At Life's End : Shots - Health News Blog : NPR

Wednesday, January 5, 2011

Helping patients experience death, PhillyBurbs.com:

I'll Never Ration. Not Me. Not I. - NYTimes.com

Saturday, January 1, 2011

Discussing cancer treatment with the terminal patient, KevinMD.com

Sunday, December 19, 2010

Death in a hospital is not always comfortable, KevinMD.com

The cost of keeping the terminally ill alive, KevinMD.com

Wednesday, December 15, 2010

Cancer patients die too often in hospitals, study says - The Boston Globe

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