Why Hospice is More Important Today than Ever Before

The Affordable Care Act is driving all health care providers to find ways to improve outcomes in an environment of declining reimbursements. As payments go down, it’s important to consider how health care as a whole can increase efficiencies by providing hospice and palliative plans to end-of-life patients who need them most. A few facts to consider:

If you’re starting to think my suggestion to bolster palliative care is singularly financial, consider the study excerpts below:

Bottom line: hospice is not a bleak sentence; it’s a healthy option preferred by patients and their families.

Hospice caregivers make house calls.

Maggie Riley, a nurse practitioner at the Atlanta VA Medical Center puts it this way: Palliative care is about therapeutic relationship-building and interpersonal skills. It’s about listening intently, restating and reclarifying, so that you understand what a patient knows and what they need or want to know in order to make good decisions.

Serious illness affects a person physically, psychologically, socially, and spiritually. Patients are often confused about many aspects of their situation. Some can’t comprehend what they’ve been told about their disease state and their likely outcomes. Others don’t understand their treatment options or know about their medical benefits. In some cases, they may be hoping for a cure that just is not possible.

Patients and their families need to know and understand their options.

Riley says it like this: No one wants to talk about these things but talking about them early can relieve stress and suffering, and make sure that a patient’s wishes are honored.

Having these discussions is terribly difficult but absolutely necessary. Not because the cost to care for these patients is reduced when they accept the inevitable, but because we have access to data-driven tools that provide the benefit of time — time that can be used to ensure quality of life.

On a personal note, I don’t want my parents and loved ones to exit this world in the clinical sterility of a hospital room surrounded by dedicated and capable strangers, but strangers nonetheless.

Further, I unequivocally do not want to die in a hospital. I am one of the 70 percent of Americans who wants to die at home. I will be in my bed, surrounded by people who love and care for me, who

Patients deserve to be informed.

Patients deserve to be informed.

are all bawling in an almost debilitating manner so that I am afforded one last little dose of ego stroking before I go. But that’s just me.

We, as a health care community, have the tools to make this scene — tears or no tears — a reality for more people than we ever have before. Predictive modeling is the answer. It can analyze clinical data and glean from that data a comparative insight into a patient’s likely term far earlier and more accurately than ever before. These analytics can provide families and patients a longer runway to consider, evaluate, and understand their options. What critically ill patient wouldn’t want to be made aware of palliative options if it meant a more comfortable existence and possibly even a longer one?

One of the fibers of our fabric as Americans is an attitude of eternal optimism and perseverance.

Never Give Up!—

Undeniably words to live by, but not to die by.

It is incumbent upon us to embrace our inevitable mortality when that stage is reached. It is incumbent upon us to guide patients into the right care venues to afford them an opportunity to seize and savor that last segment of life.

Thirty days of pain-free time at home with my loved ones is a far better option for me and for most people, than six months of procedures and needles and hospital rooms. We owe it to our patients to give them this option and we have the tools to do so.

As shown in the bullet points above, there is a major mismatch between people’s preferences for where they would like to die and their actual place of death. We can and should improve upon this. That is why using the emerging predictive technologies to better deliver hospice and palliative care is more important now than ever.

 

Dan HoganAbout the author: Dan Hogan is the CEO and founder of Medalogix. His company is a predictive modeling web service that analyzes data, like patient records, that post-acute agencies already have on hand to generate valuable patient insights. In 2012, the Healthcare Information and Management Systems Society awarded Medalogix the Health Information Technology award, which recognizes the software as one of the best emerging technologies in the Southeast. Dan can be reached at dan@medalogix.com.

 

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5 Surprising Facts About Palliative Care

There’s an important medical term that you may not have heard of: Palliative Care. “Palliate” means to make comfortable by treating a person’s symptoms resulting from a serious illness. Hospice is one form of this care that many Americans have heard of. Palliative Care is much more comprehensive than many people realize.

1. It’s More Than Just Pain Relief

Palliative care focuses on helping a person be comfortable by addressing all symptoms that cause physical distress: pain, digestive issues, swelling, difficulty breathing, etc. Palliative care professionals are experts at managing all symptoms associated with serious illness. Additionally, this care addresses the spiritual and emotional needs of patients.

2. It’s Delivered By A Team

Hospice and other palliative care providers utilize teams consisting of doctors, nurses, nurses aides, social workers, counselors, chaplains, and trained volunteers, working together to provide, physical, emotional, social and spiritual care.

3. Palliative Care Includes The Patient’s Family

The goals of care are to improve the quality of a seriously ill person’s life and to support that person and their family (or support network) during and after treatment.

4. It’s Not Limited To Hospice

For more than thirty years, hospice programs have been providing palliative care for people at the end of life. Hospice serves more than 1.65 million patients and their family caregivers each year. Hospices are the largest providers of palliative care services in the county. However, this very same approach to care is being used by other healthcare providers, including teams in hospitals, nursing facilities and home health agencies in combination with other medical treatments to help people who are seriously ill.

5. It’s Available At Any Time During Illness

If it can help make life more enjoyable, why wait? Palliative care may be given at any time during a person’s illness, from diagnosis on. Under hospice palliative care, a patient focuses on comfort and quality of life. Under palliative care outside of hospice, a patient may continue with curative treatments.

Houston Hospice can help you understand more about palliative care and all the services offered by Houston Hospice. Contact our 24/7 help and information number at 713-468-2441.

Additional information on caregiving and advance care planning is available from the National Hospice and Palliative Care Organization’s Caring Connections at www.CaringInfo.org.

—Karla Goolsby, Houston Hospice Communications Specialist

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The 50th Anniversary of the Hospice Movement

This year marks the 50th anniversary of the hospice movement. It’s been an incredible success story. The Hospice Movement, including advances in palliative care and the introduction of holistic support, has been generally credited by the rise of two influential 20th century figures: (Dame) Dr. Cicely Saunders and Dr. Elisabeth Kübler-Ross.

An Unmet Need Recognized

Dame Cicely Saunders

Dame Cicely Saunders

Englishwoman Cicely Saunders was a medical social worker in 1948 when she developed a relationship with a dying Polish refugee that helped solidify her ideas that terminally ill patients needed compassionate care to help address their fears and concerns, as well as palliative (pain and symptom management) comfort for their physical condition. Saunders began volunteering at a facility for the terminally ill poor, where a  physician convinced her that she could best influence the treatment of the terminally ill as a physician herself. Upon graduation from medical school in 1957, she accepted a permanent position in a hospice facility in East London, where she continued to research pain control.

Saunders introduced the idea of specialized care for the dying to the United States during a 1963 visit to Yale University. Her lecture, given to medical students, nurses, social workers and chaplains about the concept of holistic hospice care, included photos of terminally ill cancer patients and their families, showing the dramatic differences before and after the symptom control care.

St. Christopher's Hospice

St. Christopher’s Hospice

In 1967, Saunders established St. Christopher’s Hospice, the world’s first purpose-built hospice, in a London suburb. It was founded on the principles of combining teaching and clinical research and providing expert pain and symptom relief with holistic care to meet the physical, social, psychological and spiritual needs of its patients and those of their family and friends. Familiar comforts of home were made available to patients, from gardening to salon hairstyling. As Saunders’ protégé Dr. Richard Lamerton later explained, a patient’s home or a home-like setting was found to be essential as a part of therapy, versus a hospital – the last place to be when one needed peace and calm.

A Plea for Empowerment and Dignity

Elisabeth Kubler-Ross

Elisabeth Kubler-Ross

In Chicago, Swiss-born psychiatrist Elisabeth Kübler-Ross was formulating her own response to the treatment of terminally ill patients in late-1960s America. Married to an American physician, she observed what she considered inadequate social responses by his hospital toward its dying patients. She began a study that would lead to more than 500 interviews with terminally ill patients.

On Death and Dying was published in 1969 and became a bestseller. A revolutionarily insightful work, it identified five stages through which many terminally ill patients progress. These stages (denial, anger, bargaining, depression and acceptance) would become widely accepted in the decades that followed as ‘the five stages of grief’. Even into the 21st century, On Death and Dying would continue to be the gold standard for education on the subject. The book was more than a simple explanation of psychological expressions, however. Within it, Kübler-Ross made a plea for care in the patient’s home as opposed to treatment in an institutional setting. She further argued that patients should have a choice and the ability to participate in the decisions that affect their destiny, including patients’ rights to refuse treatment that they felt would not be beneficial or would not improve their quality of life.

Testimony Leads to Federal Support

In 1972, the United States Senate Special Committee on Aging conducted the first national hearings on the subject of death with dignity. Kübler-Ross was asked to testify. In her testimony, she capitalized on the opportunity to emphasize the benefits of patient care in the patient’s own home: “We live in a very particular death-denying society. We isolate both the dying and the old, and it serves a purpose. They are reminders of our own mortality. We should not institutionalize people. We can give families more help with home care and visiting nurses, giving families and patients the spiritual, emotional, and financial help in order to facilitate the final care at home.”

The impacts of Saunders and Kübler-Ross redefined hospice care across the globe: comprehensive care for the patient’s physical, social, psychological and spiritual needs; patient empowerment to make decisions about the type of care they wish to receive or not receive; emphasis on at-home care for best patient comfort when possible; and an expanded circle of care to include the patient’s family and friends.

In 1978, a report by a U.S. Department of Health, Education, and Welfare task force noted both the altruistic and practical advantages of government support for hospice care: “The hospice movement as a concept for the care of the terminally ill and their families is a viable concept and one which holds out a means of providing more humane care for Americans dying of terminal illness while possibly reducing costs. As  such, it is the proper subject of federal support.”

The Hospice Movement Comes to Houston

In 1980, Houston’s first hospice, Houston Hospice, was founded. The same year, New Age Hospice was formed, which later merged with  Houston Hospice. New Age Hospice’s primary organizer, Marion Wilson, was determined to establish a source of humane, caring responses for dying patients and their families, following the loss of three of her children.

In 1981 Houston Hospice (as New Age Hospice) began accepting patients. Its first Medical Director was Dr. Richard Lamerton, a revered

authority on care of the terminally ill who had been the first intern trained by Dame Cicely Saunders at St. Christopher’s Hospice in London.

A 1985 visit by Princess Diana to St. Joseph’s Hospice. One of its founders, Dr. Richard Lamerton, became the first Medical Director of Houston Hospice.

—Karla Goolsby, Houston Hospice Communications Specialist

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Are Baby Boomers Changing the Way We Die?

Quality of life. Hope. Living before leaving.

The nature of death and dying has evolved dramatically over the past century, driven in great part by Baby Boomers.

“A Good Death: How Boomers Will Change the World a Final Time” asserts that many in this generation are embracing the idea that quality of life should be the most important issue for patients and families facing terminal illness.

Think You’ve Covered the Bases? Better Check Again.

Tom Brokaw felt confident that he was prepared until this TED Talk. Here his doctor daughter interviews the NBC journalist about his future health care wishes.

Get Started (Hint: You Don’t Have to Be a Boomer)

Call 713-677-7118 or email to request an Advance Planning Packet filled with information about how to write a Life Review, how to talk to your family, and necessary legal forms such as Medical Power of Attorney and Texas Directive to Physicians and Family or Surrogates. You may also download Advance Directive forms here.

—Karla Goolsby, Houston Hospice Communication Specialist

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Veterans’ Day: A Reminder that Heroes Walk Among Us

frank_hay

Frank Hay

The 68-year-old courier has tried to put his memories of the unpopular war in Southeast Asia behind him. He certainly doesn’t think of himself as a hero. Nevertheless, while Frank Hay was making his rounds at Houston Hospice recently, his Vietnam Veteran ball cap was spotted by a staff member who thanked him for his service. He nodded his thanks and thought he’d be on his way until the staff member invited him to talk about the war. Houston Hospice is part of The National Hospice and Palliative Care Organization’s “We Honor Veterans” program. As a result of learning more about the needs of veterans and their families, staff members have a tendency to notice vets.

An 18-Year-Old in America

In 1966, 18-year-old Frank Hay and his family lived a quiet country life on the banks of a lake outside North Guilford, Connecticut. North Guilford is a pleasant town with a volunteer firehouse, a general store and a gas station. As a kid, Frank got a kick out of walking on the lake’s barely submerged island to the astonishment of visitors who thought he was walking on water. With a school career frustrated by dyslexia behind him, Frank went to work as a Railway Postal Clerk. He counted bags of mail that were loaded and unloaded from rail cars as part of the Railway Post Office (RPO). Frank’s family knew young men were being conscripted to assist with a conflict in a place called Vietnam, so they weren’t surprised when he was drafted.

Frank was sent to Fort Gordon, Georgia for pre-induction physical examinations and testing. His dyslexia caused the army to suspect he was faking to get out of service. However, additional testing revealed a high IQ and the kid who grew up deer hunting in the woods of Connecticut was trained to be a gunner on a helicopter. During basic training Frank recalls thinking the war was a game. “I thought we’d come in and say ‘John Wayne’s here. Step aside.’ The first time someone got shot, I thought, ‘Wow! This is real.”’

Confusing New World

military-1348281_640

Frank’s first impressions of Vietnam were clouded by confusion. “We’re in our own world in the U.S. and when you go there you realize things are not the same.” He felt disoriented to be in a place where people were so impoverished that they were forced to sell a child rather than part with a cow. Frank had been in Vietnam only seven months when his helicopter was hit by enemy fire and crashed killing the pilot and co-pilot. He was captured immediately by the enemy who took him into the jungle where they were holding other prisoners of war. There were no POW camps at that time so the enemy cut the sole of Frank’s foot to prevent him from escaping.

Prisoner of War

He remembers being moved constantly for 14 months. “I talked with other prisoners but I didn’t become close because a lot of them died. Some of them went loony.” Fellow POWs died of disease and starvation. Frank figures he lost about 50 pounds. “We’d stay in a hole dug in the ground with bars over it. They fed us rice and fish. I’ll never eat rice again.” During the constant moves, the prisoners were separated and brought back together. Whenever Frank’s foot began to heal, it was cut again. “I took my anger out on God. I’d say ‘Why did you let this happen?’ ‘Why don’t you do something?’ I couldn’t be mad at the enemy. They were soldiers too.”

One day while the prisoners were out of their holes for a move, their encampment came under fire from a U.S. Army helicopter. Everyone ran. Guards ran. Prisovietnam_1967ners ran — in all directions. Frank ended up half running and half hobbling with two other prisoners. “We just kept running until we ran into a U. S. Army unit.” He was taken to a field hospital where he was treated and debriefed. From there, Frank went to a VA hospital. After his injuries healed he was sent home.

People Asked Why I Was There

Frank didn’t stay in touch with any of the guys he met in Vietnam. He didn’t keep a uniform, or a photo or any memento of his service. “After the war, people asked why I was there and why I was fighting and killing. We were just soldiers on both sides. We were only doing what we were told. I just wanted to get on with my life.” Frank recalls being spit on and called a baby killer. He went to the VFW Hall in Guilford, Connecticut where he was ridiculed. “The other vets said that Vietnam was not really a war.” Frank resents being denied camaraderie at the hall. “In those days they had dances, parties and baseball games. Now it’s just a place to go drinking. I’m tired of older people coming up and shaking my hand. Where were you when I came home?”

Frank doesn’t like to talk about the war. But in an act of extreme generosity, he did. He did move on. He moved to Houston and, at 50, met and married his wife who hails from Buffalo, New York. Frank has no desire to return to Vietnam. The courier has moved on but some wounds remain.

We Honor Veterans

About Houston Hospice: As a leader in hospice care for people of all ages and all walks of life, nonprofit Houston Hospice provides for the distinct needs of Veterans and their families through its We Honor Veterans Program. Care is provided to patients and families in private homes and in residential facilities throughout Houston and 10 surrounding counties. Inpatient care is provided in the Houston Hospice Margaret Cullen Marshall Hospice Care Center in the Texas Medical Center. To learn more about the We Honor Veterans Program and other services, call 713-468-2441 or visit www.houstonhospice.org.

—Karla Goolsby, Houston Hospice Communication Specialist

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Death, Driving and Dollars: 7 Strategies to Discuss Taboo Topics

Discussing Taboo Topics with an Elderly Loved One

Man wearing money sign - Discussing money is always sensitive.No one relishes the thought of pondering death for too long. Aging adults don’t want to consider what giving up the keys to the car will mean for their independence. And, thanks to the prevalence of identity theft, financial information always has an aura of silence surrounding it.

However, as you begin assuming more and more responsibility as a caregiver, there will come a time when you will have to discuss these awkward issues with an aging family member.

7 Strategies for Discussing Sensitive Subjects with an Elderly Loved One:

  1. Don’t give advice unless it’s asked for: This is an especially important tip for adult children who are looking after their aging parents. Your mother and father are used to providing you with advice and guidance. When this dynamic begins to shift, it may start to lower their self-esteem and make them feel out-of-control. Getting an outside expert—such as a financial advisor, or elder law attorney—to provide professional guidance can make an elder more receptive to new information.
  2. Pick your battles: It’s likely that your loved one needs help with multiple tasks—don’t try to tackle all of them in a single conversation. Prioritize their needs and address those needs over a series of discussions. This will allow each talk to remain focused on identifying a single problem and all of its potential solutions.
  3. Listen to what they’re saying: Make sure you’re really listening to what your loved one is saying. Try not to interrupt, or fill the silence during a conversation. When it’s your turn to speak, Mother and son having discussion in kitchensummarize what you think your loved one just said and then ask them if you have correctly interpreted their sentiments.
  4. Accept differing viewpoints: Expect and accept disagreement, especially when discussing hot-button topics. Acknowledge your loved one’s questions, concerns and viewpoints. Try to come up with a compromise that everyone can accept.
  5. Speak calmly and clearly: Especially if things begin to get heated, avoid raising your voice or shouting during a conversation. An argument can quickly escalate if either party starts acting flustered. Also, when speaking to older adults with hearing issues, it’s important to keep your voice low and to make sure to properly annunciate. This will smooth the communication process by ensuring that your loved one is literally hearing what you have to say.
  6. Don’t patronize: No one likes to be talked down to, especially if they’ve been living decades longer than the person they’re conversing with. Even if you’re talking to someone who suffers from Alzheimer’s, or some other form of dementia, don’t infantilize them by speaking to them the same way you would speak to a child.
  7. Choose your setting carefully: Plan out where you want the conversation to be held. Pick an area that is quiet and has few distractions (television, radio, too many people). Make sure you’re facing your loved one at all times.
  8. Put yourself in their shoes: Remember that your loved one is probably feeling like they are losing control over their own life. In their mind, their freedom and independence are being threatened. Be mindful of these feelings and approach every discussion with sensitivity and empathy.Asian mother and daughter having discussion outdoors

Provided courtesy of AgingCare.com, the go-to destination for family caregivers. AgingCare.com offers resources and support to help guide family members through difficult conversations, like talking with parents about death or money. This article is one of a series of articles included in the eBook, Family Caring for Family. Download your free copy at www.AgingCare.com/ebook.

 

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Paying For End-of-Life Care

Baby Boomers Feel the Squeeze

Man Paying Bills

Concerns over the costs of healthcare are shared by almost every family across the country. Many baby boomers are providing care for their aging parents just as they are facing their own health care issues.

Yet, for almost 30 years, the Medicare Hospice Benefit has provided a model for financing end-of-life care that can bring great relief and support to families during one of life’s most difficult times.

This benefit covers virtually all aspects of hospice care with little out-of-pocket expense to the patient or family. As a result, the financial burdens often associated with caring for a terminally-ill patient are lifted.

Hospice care also offers supports to the loved ones of the patient; this brings an added level of relief to the dying person, knowing their loved ones are being cared for as well.

Hospice is paid for through the Medicare Hospice Benefit, Medicaid Hospice Benefit, and most private insurers.

Medicare covers these hospice services and pays nearly all of their costs:

Medicare will still pay for covered benefits for any health problems that aren’t related to a terminal illness.

Hospice Means More Medical Care, Not LessTeam of medical professionals

Hospice and palliative care involves a team-oriented approach to expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. Families making end-of-life decisions for a loved one need compassion and support, not financial worries. The Medicare Hospice Benefit helps alleviate these concerns.

To learn more, contact Houston Hospice at 281-468-2441 or 800-824-2911 or at info@houstonhospice.org.

To find a hospice or learn more about hospice care, visit Moments of Life at www.MomentsOfLife.org.

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Houston Hospice Nurses Receive Prestigious Award

Good Samaritan Excellence in Nursing Award

Houston Hospice nurses Hope Cook, Svanhaniel Crim and Darelle Robbins received the Bronze Excellence in Nursing Award from the Good Samaritan Foundation at a luncheon ceremony on September 8, 2016 at Houston’s Royal Sonesta Hotel. The event was chaired by Kathryn M. Tart EdD, MSN, RN, founding Dean and Professor of the University of Houston School of Nursing. This year 249 nurses were nominated by their peers from hospitals, clinics, colleges and universities throughout Houston.

Hope_Cook_Recieved_Excellence_In_Nursing_AwardHope Cook

Hope Cook BSN, RN, CHPN has been a practicing Registered Nurse since graduating from Texas Woman’s University, Houston 41 years ago. This year she tackled a new role as Educator for Houston Hospice. Hope has created several educational programs and works diligently toward positive outcomes in patient care through education. Hope’s colleagues note that she tenaciously seeks the latest information to stay abreast of changes in the hospice specialty. Her educational programs have enriched and supported the Houston Hospice nursing team.

Svanhaniel_Crim_Received_The_Excellence_In_Nursing_Award

Svanhaniel Crim

Svanhaniel (pronounced Swan-Nell) Crim BSN, RN embarked on her nursing career 40 years ago, after graduating from the University of Texas System School of Nursing. She has served as a leading member of her Houston Hospice care team for over six years. Because of Svanhaniel’s diverse experience and penchant for learning, she is a go-to person for nurses and physicians. Svanhaniel is eager to help her colleagues succeed and she is often called upon to act as a mentor and educator for new employees, nursing students and medical residents from nearby programs. Svanhaniel is also well-known for her exceptional bedside manner. Patients and families frequently express gratitude for the care she provides.

darelle_robbins_received_the_excellence_in_nursing_awardDarelle Robbins

Darelle Robbins MN, RN has been an RN since graduating from Odessa Junior College. She earned a BSN in 1979 from the University of Texas in Austin and completed her Masters in Nursing in Staff Development, Clinical Nurse Specialist degree in 1990 from LSU in New Orleans. Darelle’s Houston Hospice care team says she has been an inspiration to them with her positive attitude and can-do spirit. Darelle steps in when nursing needs arise, even traveling from Houston to El Campo to Humble in one day to see patients. At their weekly care team meetings, Darelle shares her wealth of knowledge making valuable contributions toward patient care planning. Beyond her medical expertise, families express appreciation for the calming and reassuring presence Darelle provides.

Thank you Hope, Svanhaniel and Darelle for your expert medical care and for providing comfort, dignity and reassurance for patients and families. You truly care and it shows.

Work with the best of the best. Houston Hospice employment opportunities.

 

—Karla Goolsby, Houston Hospice Communication Specialist

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Report: Senior Health Care Misses the Mark

Report Details Senior Health Care That Misses The Mark

By Michelle Andrews

Quality over quantity. As people get older, their health care goals may shift away from living as long as possible to maintaining a good quality of life. In key areas, however, the medical treatment older people receive often doesn’t reflect this change, according to a new study.

The wide-ranging report from the Dartmouth Atlas Project uses Medicare claims data to examine aging Americans’ health care. Among other things, it identified five key areas where too many older people continue to receive treatments that don’t meet established guidelines or, often, their own goals and preferences.

Two of the five have to do with preventive care that may not benefit seniors: screening for breast and prostate cancer. The other three address care at the end of life: late referral to hospice care, time in the intensive care unit in the last six months of life and placing feeding tubes in patients with dementia.

While the measures themselves are quite different, they each highlight the need for better communication and shared decision-making among patients, their families and their medical providers.

“Where there are harms and benefits and people judge them differently, that’s where the shared decision-making comes in,” said Dr. Julie Bynum, an associate professor at the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, N.H.

Despite the simplicity of a mammogram or a blood test to check for prostate cancer, if the screening is positive for cancer, that can set off a cascade of further testing and treatment. Those efforts could cause harm to older patients, whose health may be fragile or who have multiple medical conditions.

In addition, older people may well die from something else before a cancer progresses, said Dr. Richard Wender, chief cancer control officer at the American Cancer Society.

“The single hardest concept for the public to understand is the natural history of finding a cancer through a screening process,” Wender said. “Many people have the sense that had it not been found that cancer would have threatened their life within a couple of years or maybe even a couple of months.”

Experts have cautioned older patients about both tests. The U.S. Preventive Services Task Force, an independent panel that weighs evidence and makes recommendations about prevention services, has concluded that prostate cancer screening isn’t beneficial at any age and said that there’s not enough evidence to know whether women benefit or risk harm by undergoing breast cancer screening after age 74.

Medical treatment older people receive often doesn’t reflect their wishes.

Still, the Dartmouth Atlas analysis found that 20 percent of male Medicare beneficiaries age 75 and older got a PSA test to screen for prostate cancer in 2012, and 24 percent of female beneficiaries that age had a mammogram to screen for breast cancer that year.

We Need To Make Decisions Based On The Patient’s Values

Guidelines aside, clinicians and their patients need to discuss the pros and cons of testing and make a decision based on the patient’s values and preferences, experts say.

For example, a 75-year-old woman who is willing to accept that she might actually die of breast cancer within 10 years but wants to avoid the anxiety and harms of treatment, might choose not to be tested.

“I ask people, ‘Do you think you’re going to be around in 10 years? Help me decide’ whether to order a mammogram,” said Bynum, whose work focuses on geriatrics.

As people near the end of their lives, it’s especially important for patients and their family members to discuss their goals and wishes with clinicians. Patients often want to be kept comfortable rather than undergo medical interventions, but physicians and nurses are still trained to do everything possible to prevent death, said Dr. Diane Meier, director of the Center to Advance Palliative Care and professor of geriatrics at Mount Sinai’s Icahn School of Medicine in New York.

The three end-of-life criteria that the Dartmouth researchers cited are areas that geriatrics experts agree are critical but have proven difficult to get providers, health systems and the general public to accept, said Bynum. Late referral to hospice and spending time in a hospital intensive care unit can adversely affect terminal patients’ health, result in higher costs and run counter to their hope for a peaceful death. Feeding tubes in patients with advanced dementia can lead to other complications.

Lost Opportunity: Hospice Comfort Care Services That Are Available For Months Are Not Utilized

The Dartmouth study found that in 2012, 17 percent of Medicare beneficiaries who died were enrolled in hospice only during the last three days of life. Medicare, however, will approve hospice benefits, which generally include comfort care rather than curative treatment, when the physician certifies that someone is expected to live for no more than six months.

The study also found that people spent an average of nearly four days in intensive care during the last six months of life, a figure that is trending upward.

Finally, even though it doesn’t prolong their lives to place feeding tubes in patients with dementia, who naturally lose interest in food and their ability to swallow in the final stages of the disease, 6 percent of Medicare beneficiaries with dementia received them in their last six months of life in 2012.

Communication is key, but the skills that are needed to counsel patients aren’t being taught, said Meier.

“If you unleash an oncologist who does not know how to say, ‘Your cancer has progressed,’ but they know how to say, “I know what we can try,’ that’s why people end up in the ICU and with feeding tubes” at the end of life, she said. “It’s easier than having a difficult conversation.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.

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Taking a Lesson from Muhammad Ali

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The Champ Did it Right

I’m one of those adults who doesn’t have an up-to-date will or a signed Medical Power of Attorney. I know better, and now, I’m going to take a lesson from the Champ, Muhammad Ali. His funeral was ten years in the making. An Ali family spokesperson said the boxing legend, acclaimed civil rights icon, and humanitarian personally planned the details of his funeral over a ten-year period. Because I work at a hospice and my husband is a pastor, I’m frequently in the know about the end-of-life wishes of elder friends. Here’s the thing though, this task is not just for the elderly.

Ask Questions

Ask Yourself Basic Questions

While it may feel scary or overwhelming to think about our own deaths, asking yourself basic questions about how and where you’d want to die is a critical first step. Would you prefer to be at home? Do you envision attempts to keep you from dying with resuscitation and life support measures or do you prefer a natural death? These are not easy conversations to have with our loved ones. But they are necessary ones if we want to leave this world on our own terms and ease the burden loved ones will face when it’s our time to go.

According the National Hospice and Palliative Care Organization, the very people we expect to help guide us through these conversations are not well prepared. A recent national poll found that while almost all doctors think having end-of-life conversations with their patients are important, nearly half said they frequently or sometimes feel unsure of what to say and less than one-third reported having had any formal training specifically on talking with patients and their families about end-of-life care. Because our medical culture default is set up first to keep people alive at all costs. Conversations about how to die can be seen as going in opposition to that cultural norm.

Legal surrogate

So, What to do?

Identify a legal surrogate decision maker. This person is someone you trust to follow your wishes if ever you are unable to communicate. Any adult can serve as your surrogate regardless of whether they are related to you or not.

Additionally, complete a living will or advance directive. This shouldn’t replace conversations with loved ones or your legal surrogate. However, completing these will express your values and wishes around life support and serve as a guide for loved ones and your healthcare providers. Houston Hospice provides complimentary packets filled with hard copies of information about how to start this important conversation along with Texas Medical Power of Attorney and Texas Directive to Physicians and Family or Surrogates forms. (Email kgoolsby@houstonhospice.org or call 713-677-7118 to request a packet.)

Medical Power of Attorney

Knowledge is Power

Next, familiarize yourself with palliative and hospice care. Palliative medical care focuses on helping seriously ill patients and their families and provides and extra layer of support to address symptoms and the stress of being ill during any phase of treatment.

Hospice utilizes palliative care, plus it adds additional end-of-life medical, social, emotional and spiritual support for patients who have been diagnosed with a life-limiting illness and their families. Hospice care can be provided at home, in an assisted living community, or in an inpatient care setting. Most people do not want to die in a hospital. However, when ill, all roads lead to hospitalization and once in the hospital, many barriers can prevent a transition home. It’s important that loved ones and healthcare providers know your preference in advance.

Most of us won’t need to spend 10 years planning as Ali did. But we need to think carefully about our values and wishes and, most importantly, we need to share our wishes with loved ones.

—Karla Goolsby, Houston Hospice Communication Specialist

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