Archive for June, 2016

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

muhammad-ali-punch_2856798k

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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