Hospice and Palliative Medicine

Palliative Care for Cancer Patients in Treatment

by Porter Storey, MD, AAHPM Executive Vice President

Palliative care teams should be consulted more often for cancer patients in active treatment.

I know, I am “preaching to the choir” on this blog, but it may be important how we explain this to our various “stakeholders.”

The Public – Palliative care can help align patient wishes with their treatments and make sure patients and families are comfortable and supported.

Patients – Palliative care can help with symptom management, care coordination, psychosocial support so that you can continue your treatment and continue to do so after it is completed.

Hospice Programs – Palliative care can provide support before they qualify for hospice and refer patients to hospices sooner, for longer lengths of stay.

Payors and Program Administrators – Palliative care consultations can reduce costs and improve quality for the sickest (and most expensive) patients we care for. It can reduce hospital readmissions and save thousands of dollars per hospitalized patients (for the latest of many articles see Nelson C, et al. Inpatient Palliative Care Consults and the Probability of Hospital Readmission. Permanente J. 2011, 15(2):48-51.)

Referring Oncologists – Palliative care can act as an extension of the oncology care team so oncologists can focus on giving treatment. And as Tom Smith and Bruce Hilner argue in the May 26 NEJM, “bend the cost curve” so that we can afford to offer expensive new treatments to patients who can benefit from them (N Engl J Med 2011; 364:2060-2065).

Let’s not apply the wrong argument to the wrong class of stakeholders.

What do we say to the politicians?

Join the discussion when AAHPM offers the webinar “Changing the Mindset: Integrating Palliative Care into Cancer Treatment” lead by Tom Smith on Tuesday July 14 at 3pm ET.

Update from the AMA 2011 Annual Meeting

by Chad D. Kollas, MD, FACP, FCLM, FAAHPM – AAHPM Delegate to the AMA

While in Chicago from June 18-20 to represent the Academy at the Annual Meeting of the American Medical Association House of Delegates, my colleague Dennis Pacl, MD FAAP FACP – AAHPM’s alternate delegate – and I took in a show one night…. We saw Steve Martin and Martin Short at the historic Chicago Theater in what was billed as “A Very Stupid Conversation.” Now, I know that some question the continuing relevance of the AMA, but I would assure all AAHPM members that our time spent at the AMA Annual Meeting was anything but stupid. In fact, I am pleased to say that this gathering of physicians representing state and specialty medical societies featured some very thoughtful conversations, many that impact the future of medicine and a number that are key to our field.

I was honored to have been elected in November to chair the AMA’s Pain and Palliative Medicine Specialty Section Council (PPMSSC). As representatives of nine diverse specialties, the PPMSSC reviews the reports and resolutions before the House with implications for the pain and palliative medicine communities and decide where to provide testimony and offer joint endorsement or opposition. One resolution, sponsored by the Iowa delegation, called for a national dialogue by interested parties on end-of-life (EOL) counseling. AAHPM testified in favor of the resolution and identified the Academy and PPMSSC as interested in serving as resources in the endeavor. The AMA House of Delegates adopted the resolution as new AMA policy, and we’ll provide timely updates on the effort. Another resolution, sponsored by the American Thoracic Society, led to a recommendation that the “AMA encourage the Centers for Medicare and Medicaid Services to designate voluntary discussions about end-of-life care as covered services in the 2012 Medicare Physician Fee Schedule.” These efforts – which harmonize with the Academy’s policy priorities – build upon an opinion by the AMA Council on Ethical and Judicial Affairs approved by the AMA House in November 2010, which encouraged physicians to participate in advance care planning.

The AMA House also passed a resolution that called for reform of the Patient Protection and Affordable Care Act (PPACA). Although the PPACA contained many directives consistent with AMA policy, such as expanding health insurance coverage for Americans, it also contained provisions considered undesirable or controversial. The AMA specifically called for repeal of the Independent Payment Advisory Board (IPAB), enactment of comprehensive medical liability reform, studying further the Medicare Cost/Quality index and expanding the use of health savings accounts (HSAs). Support for individual responsibility for health insurance to cover the uninsured was also reaffirmed read more.

The House also accepted a report from CEJA regarding ethics rules guiding industry support for continuing medical education (CME). A representative from the Accreditation Council for Continuing Medical Education (ACCME) testified that the new ethics rules were consistent with current ACCME standards. AAHPM already conforms to both the ACCME standards and the new AMA standards, and also signed on to the Council of Medical Specialty Societies’ Code for Interactions with Companies.

Finally, some issues of interest to palliative care physicians were referred for further study by the AMA. The Florida Delegation sponsored a resolution asking the AMA to study the issue of national or regional drug shortages, a problem that has profoundly affected palliative care specialists over the last several years. Additionally, AAHPM supported studying the content of patient navigators programs to enhance their consistency. The AAHPM Delegation to the AMA will make the findings of the reports available to Academy members when that information becomes available.

Beyond the annual meeting, our collaboration with members of the PPMSSC continues. This summer, we’ll develop comments on a resolution addressing the right of access to medication for pain relief that will be presented later this year at the World Medical Association meeting. In the meantime, if there are issues that you believe we should take to the “House of Medicine,” I welcome your thoughts. I also hope that if you’re not an AMA member, you will consider joining? (be sure to specify HPM as your specialty if you do) – AAHPM’s representation and participation is dependent on having a sufficient number of Academy members among the AMA’s ranks.

Eager Medical Students Learn about Palliative Medicine

by Emily Muse, AAHPM Manager, Communities and Programs

Saturday was the opening of the American Medical Association House of Delegates Annual Meeting 2011. One of the featured events was the eighth annual AMA-MSS Medical Specialty Showcase.
The American Academy of Hospice and Palliative Medicine was invited to exhibit at this event and took the opportunity to educate current medical students about the field of Hospice and Palliative Medicine.

Eager medical students visited booths exploring what options may be available to them. In narrowing down these career directions they asked a lot of questions, “Is HPM strictly for Family Medicine Residents ?”, “How long is a Fellowship in HPM? ”, “Can I practice HPM if I am a pediatrician?” , “What are the boards that sponsor this subspeciality” and “How many HPM fellowship programs are there?”. By the halfway point of the day I was “questioned out”! It was then that a young gentleman approached the booth. Before I could speak, he immediately introduced himself and said
“My Dad is a member of your organization, he just took the certification exam, I felt like I needed to stop by. I am not sure this is the right career path for me, but I know what a difference Palliative Care makes.”
It was so sincere and genuine, I almost asked if he would like to stay and work at the booth for the rest of the allotted time! While he moved on through the crowd investigating other medical specialties and subspecialties I was reminded that Hospice and Palliative Care is much more than the answers to the basic questions about fellowship. It is a philosophy of care that is driven by clinicians committed to patients as they navigate life limiting or life challenging conditions.

And the best answer is…

by Bruce Chamberlain, MD and Julie Bruno, MSW, AAHPM Director of Education

You’ll recall the case of Mary Jane initially introduced in the May 26 AAHPM e-News.

Mary Jane was on service with the diagnosis of adult failure to thrive. She fell and was hospitalized with a fractured trochanter. Her pain was poorly controlled but she was scheduled to be discharged to home. Unfortunately, her family was unavailable to receive her till later in the week. You recommend…

1. Respite Care

2. GIP at a local skilled nursing facility

3. Provide continuous care

4. None-of-the-above: it’s the patient/family’s responsibility

The “correct” answer provided was respite, but, as noted by a number of you, there is an important factor that makes GIP a better answer: Pain was uncontrolled. Management of uncontrolled pain is a skilled need that would qualify the patient for GIP care. The duration of the GIP admission will be limited by how long it takes to manage the pain not the return of the family, so if, when the pain is managed, the family has not yet returned, then respite would be the best transition option. CMS has clarified that GIP should only be used based on the patient condition and should not be used due to caregiver “breakdown”. (CMS Quarterly Provider Update April 2007, http://www.cms.hhs.gov/quarterlyproviderupdates/downloads/cms1539p.pdf)

Continuous care could also be a reasonable choice, the requirement for skilled care is the same and it is a good option for a patient who really does not want to be in a facility. Documentation is more rigorous, reimbursement can be problematic and staffing can, at times be a challenge for some agencies, so most would elect to pursue the GIP option.

Key Points:

1. Respite is for the benefit of the family and is generally a planned event, it is also appropriate to use in cases of caregiver breakdown when there is not a skilled care need requirement for the patient.

2. GIP is to provide skilled care for the patient that cannot be provided in the home. Documentation for GIP based on pain must include:

  • Frequent evaluation
  • Frequent medication adjustment
  • Aggressive interventions to control the pain

AAHPM Staff Gets Firsthand Look at Palliative Medicine

by Christina Rowe, AAHPM Account Coordinator

Though I have previous experience with medical associations prior to joining the AAHPM staff, most of my experience with Hospice and Palliative Care was in a personal capacity. For the past few years as we worked with my father’s physicians to keep him comfortable, our goal was to give him the best quality of life with the time he had remaining. From the patient side you’re often too worried about if you’re making the right decisions, or spending your time with your loved one in the best way possible, rather than to step back and think about where the care is coming from or the training the physicians completed to bring your loved one quality care. So recently when another staff member and I were given a special opportunity to visit AAHPM member Dr. Stacie Levine at University of Chicago Medical Center, it was from a new vantage point for me. Throughout the day we were also able to speak with Dr. William Dale, Chief of the section of Geriatrics and Palliative Care, and Dr. Monica Malec, Assistant Professor of Medicine and a colleague of Dr. Levine’s and to learn of their roles in geriatrics and palliative care.

In a whirlwind afternoon, Dr. Levine gave us tours of the various practice settings where fellows of the University of Chicago palliative care program complete rotations. We were able to visit the hospital, the oncology clinic, a long-term care location, and the in-patient hospice they work with. The program demonstrated the many different facets that create the fine balance of palliative care.

The fellowship program makes an effort to have the fellow follow patients through each new shift in care, from hospital visits, to long term care, through hospice care. Though there are clear challenges of following a patient through many changes while balancing the fellowship program, Dr. Levine pointed out the importance of participating in the full care of the patient when possible. Though the difficulties (funding, staff time, etc) of setting up a fellowship program were clear, it was even clearer that the education and experience it provides is priceless.

One of the strongest impressions made on me came when we had been discussing how their hospice and palliative care physicians and program interacts with other specialties within the hospital, such as Oncology. While walking through the oncology clinic, Dr. Levine and Dr. Malec were explaining the importance of a palliative care physician being present, when without fail one of the Oncologists saw them and said “Oh! I have a patient I would like you to see!” Just their presence triggered the thought that palliative care should be added to the patient’s treatment.

That importance of presence resonates through so much of what makes hospice and palliative care unique. Being present in learning and teaching the many aspects of hospice and palliative care, being present in interactions with other specialties as a reminder to add Palliative care to a treatment plan, being present with the patients and their families, being present in the different stages of care for a patient, and being present in AAHPM as a voice of a growing specialty.

Thank you to Dr. Levine, Dr. Dale, Dr. Malec, and others who gave us a wonderful glimpse of their days and the University of Chicago’s program!

HMD opinions vary on the appropriate level of care…

by Julie Bruno, MSW, AAHPM Director of Education

In anticipation of the Hospice Medical Director Course in September, eNews has included some cases related to the content of the course. The last case stimulated some difference of opinion.

Mary Jane was on service with the diagnosis of adult failure to thrive. She fell and was hospitalized with a fractured trochanter. Her pain was poorly controlled but she was scheduled to be discharged to home. Unfortunately, her family was unavailable to receive her till later in the week. You recommend…

1. Respite Care

2. GIP at a local skilled nursing facility

3. Provide continuous care

4. None-of-the-above: it’s the patient/family’s responsibility

While the information we have about “Mary Jane” is limited, the answer listed in eNews was Respite Care. One member says, “I’d admit Mary Jane to GIP as her pain is poorly controlled. I recognize that her hospice diagnosis is adult failure to thrive, but pain could be a contributing factor to her global deterioration. She is too symptomatic for respite.”

Another asked, “Why wouldn’t GIP make more sense, at least for now, when the patient’s pain is reported to be “poorly controlled?”

The rationale for GIP?

The diagnosis of FTT is so broad and vague that many hospices would look at pain as part of the syndrome. Granted – the pain came from the hip fracture BUT now the patient isn’t thriving because of pain. And the hip fracture came from the debility and osteoporosis which contributed to the FTT. It is very messy. So many folks have suggested GIP because there are symptom management issues that must be addressed and cannot be safely and effectively done so in “respite”.

Another option would be skilled care rehabilitation with hospice to follow concurrently given differing diagnoses. This is fraught with problems because most nursing facilities are averse to doing this.”

What do you think?

Why do you read?

by Katie Macaluso, AAHPM Associate Editor

The newly redesigned newsletter launched in April.

We asked AAHPM members last fall why they read the Academy’s member newsletter and what they might like to see included. The result of that survey and ensuing editorial board discussions is the newly redesigned AAHPM Quarterly (formerly the AAHPM Bulletin); if you are a member, it should have landed in your mailbox during the past few weeks. The spring issue showcases a design that matches the current branding of the Academy and includes a variety of articles related to hospice and palliative care practice.

Interested in what the field of palliative care looks like in other countries such as Vietnam, Uganda, and Nepal? Read Marcin Chwistek’s article on page 12. The Art of Caring column on page 18 shares strategies for coping with the burdens of the profession through creative writing. AAHPM’s recent advocacy efforts and ways you can become involved with policy are discussed in the Advocacy Update on page 6, and Bruce Chamberlain, Gail Cooney, and Chris Acevedo unravel the specifics of face-to-face encounters on page 11. Finally, read about AAHPM President Ron Crossno and his encounter with the “presidential seal” on page 16.

Read the full issue here. (Along with the redesign, we’ve gone to a digital vender to make each issue more interactive and functional.) What do you think about the new look? What more would you like to see in the Quarterly? I know I can speak for the rest of the AAHPM Quarterly Editorial Board in saying that your opinion is highly valued and much appreciated as we continue to refine content in the newsletter.

Strawberry Shakes, an Ocean View and a Wedding

by Jen Fuhrman-Kestler, AAHPM e-Marketing Manager

“FYI…we’re getting hitched tomorrow.”

This was the text I received from my fiancé as I sat in the opening session of a membership and marketing conference. Although he made me chuckle with his deliberate flippant wording, I quickly understood the significance of what was about to happen within the next 24 hours.

My now mother-in-law, Barb, has been in poor health for the past few years, and has gone through a myriad of medical treatments for her many different serious illnesses. After a stay in the ICU, she decided to move to hospice.

Being an employee of AAHPM, and advocate of palliative care, I was pleased with her decision to focus on quality of life and relieved that her uncomfortable symptoms would be managed.

The team at Shell Point Hospice has helped align a care plan with my mother-in-law’s goals. She is a strong and independent woman, never afraid to voice her opinion. Her first request was a view of the water. Her room on the fourth floor overlooks a lagoon filled with manatees, dolphins and tarpon. After being in the ICU and limited to a few spoonfuls of ice chips, nothing sounded better to her than a strawberry milkshake. Removing all the limitations and restrictions and allowing her to enjoy her remaining days has made Barb very happy, but the greatest gift Shell Point was able to give her was perhaps the most unconventional.

When Barb’s prognosis meant that she would not be able to make our late July wedding, Shawn and I decided to bring the wedding to her. After my conference, I got the first flight to Fort Myers. The next morning, we stopped by the Publix to pick up some flowers and a small cake. When the woman at the bakery asked if the cake was for a special occasion, and we answered “our wedding,” she looked as if she didn’t believe us. We arrived at the hospice and spoke with the chaplain, Dewey. He quickly got to know Shawn and me, and within a half an hour, we had a ceremony. Michelle, the social worker, took photos, and three of Barb’s closest friends joined her to witness our promise to spend the rest of our lives making one another happy.

We are so grateful that we could share our wedding with Barb, and so appreciative of the work done by the hospice team to accommodate our rather unusual request. It was a tear-filled day, but each one shed was the result of love. Barb was beaming and counted it as one of the single-greatest joys of her life. Shawn and I were beaming too.

Lessons Learned at the ACP Meeting: Where do we go from here?

Steven (Skip) Radwany, MD, FACP, FAAHPM, is the Medical Director of Summa Health System’s Palliative Care and Hospice Services, and Professor of Medicine, Northeastern Ohio Universities Colleges of Medicine and Pharmacy. Dr. Radwany is the AAHPM Ethics, Advocacy and External Awareness Strategic Coordinating Committee Chair.

This comes in follow-up to my post a couple of months ago regarding our relationships within organized medicine and academic medicine via the Academy. I recently attended the American College of Physicians (ACP) Annual Meeting in San Diego, California, from April 5-10, 2011. I was able to obtain some of those valuable Maintenance of Certification Points during a pre-course in order to finalize preparations for my Geriatrics re-certification.

As always, this ACP sponsored meeting offered hundreds of excellent presentation from which to choose. The schedule exhibited great depth and breadth in with one significant exception:

Out of the hundreds of subspecialty and generalists offerings, including a complete track for hospital medicine, there were only 2 explicit Hospice and Palliative Medicine offerings on the schedule. These were provided by Jean Kutner, AHHPM Board Member and Keith Swetz, AAHPM Member.

Under listing of topical areas on the schedule included all of usual suspects: Cardiology, Dermatology, Endocrine, Geriatric Medicine, Gastroenterology, etc., yet Hospice and Palliative Medicine did not appear to be recognized as a distinctive or important specialty.

Nonetheless, the largest proportion of certified Hospice and Palliative Medicine specialists are internists. Additionally, the largest proportion of Hospice and Palliative Medicine Fellowship Programs are housed in or attached to Internal Medicine Programs. Thus Internal Medicine and Hospice and Palliative Medicine are clearly joined at the hip. Yet the relative absence both in name and person from Internal Medicine’s largest annual meeting suggests a bit of a disconnect.

We must collaborate extensively with Internal Medicine generalists and subspecialists in order to provide the highest quality care to our patients. We certainly need to be fully recognized and able to stand tall amongst our fellow Internal Medicine subspecialties. Some of the disconnect could reflect the integrative character of out specialty, yet General Internal Medicine, Geriatric Medicine, and Hospital Medicine all have prominent roles in this annual meeting.

Another barrier or concern might be the large number of sponsoring general specialties from which one can enter the field of Hospice and Palliative Medicine including Radiology, Pediatrics, Neurology, etc. This broad “ownership” of Hospice and Palliative Medicine may dilute the attention of organized Internal Medicine to our field though dual sponsorship of Geriatrics by Family Medicine and Internal Medicine has had no such effect.

So, where do we go from here? The concern I express above comes attached to the concern I expressed previously about HPM’s lack of recognition within the Alliance for Academic Internal Medicine. We must be visible and proactive, and we must communicate with our own Academy about existing or potential external relationships or roles we might have in other areas of organized medicine. Also, we should accept any invitations to speak at meetings such as the ACP’s and participate in leadership roles whenever possible. Sometimes to get a seat at the table you need to bring your own chair and politely elbow your way in.

And for those ACP members out there, the site below would allow you to submit a clinical skills workshop for the 2012 meeting or a presentation for the 2013 meeting:

http://www.acponline.org/meetings/internal_medicine/2011/meeting_proposals.htm

NHPCO Management & Leadership Conference through Tweeter Eyes

I attended the NHPCO Conference and this year it was different. I’m a committed member of the tweeting subculture inspired by my twitter buddies after reading live commentary from sessions at the recent AAHPM conference in Canada.

I had not planned it before going to the conference but fell into it as I listened to the first session. My initial thoughts…..take notes in the form of tweets that I can review later. But with time and the growing joy in it, I embraced the mission to benefit to the bigger audience and resolved to tweet notes that others could follow, giving credit to the presenters & bringing the message to more people. I felt like a reporter bringing tales from the edge. I reveled at bringing the results of the Moran report to the twitter community, giving insight into the issues affecting the multigenerational hospice workforce, CMS’s recommendations about the Face to Face Visit regulations or bringing eAdvocacy strategies. It changed my conference experience completely. People around me asked what I was doing punching madly on my blackberry and became starry eyed at the thought of stardom in Twitterwood!

A highlight was meeting fellow tweeters. No introductions needed, we already know each other on a different level. I laugh as I approached them in hallways and at the bookstore “Hi!—– EOLnavigator. Great to finally meet you IRL (in real life). My real name —–Niamh!”

So what’s the point of tweeting live from a conference? Our collective mission is to get everybody passionate about end of life care with something to say about it online bringing their expertise to the masses and bringing the conference experience to non-attendees. I won’t miss another AAHPM conference & you can expect tweets on the road, not literally speaking! Read our tweets for the conference at www.tweetchat.com and enter #mlc11 hashtag or follow the #hpm hashtag to meet your online hospice and palliative care brothers and sisters.

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