Archive for June, 2013

What’s Going on with Dying in America?

One of the many vexing problems in US health care is that patients repeatedly and by a wide margin express their preference for dying at home rather than in a hospital or other setting of care. However, despite that oft-expressed wish and the apparently increasing public awareness of hospice and palliative care options, most people still do not die at home. However, finally in 2011 the CDC published data that claimed an increase in people over 65 dying at home from 15% in 1989 to 24% in 2007.

Should this be cause for celebration? Apparently the answer is “maybe but maybe not”. Joan Teno and her colleagues who have tremendous experience in this area have now looked at, not only site of death, but the places of care leading up to death and the number of transitions in sites of care in the immediate pre-death period (Change in End-of-Life Care for Medicare Beneficiaries Site of Death, Place of Care, and Health Care Transitions in 2000, 2005, and 2009 JAMA, February 6, 2013—Vol 309, No. 5). Their findings are not only ambiguous, but in part troubling.

Our results confirm the CDC finding based on death certificate data that more persons aged 65 years and older are dying at home, but the rate of ICU use in the last month of life has increased, with 29.2% of decedents experiencing an ICU in the last months of life in 2009. Another indicator of change in end-of-life medical care is that 11.5% of 2009 decedents had 3 or more hospitalizations in the last 90 days of life. Hospice use increased, but 28.4% of those decedents used a hospice for 3 days or less in 2009. About one-third of these short hospice stays were preceded by an ICU stay in the last month of life. Although a hospice stay of 1 day may be viewed as beneficial by a dying patient and family, an important yet unanswered research question is whether this pattern of care is consistent with patient preferences and improved quality of life.

So what this looks like is that, while people may be dying more often at home and less often in a hospital, this change does not translate into less aggressive care at the end of life. There seems to be a significant cohort of people who are eventually getting to hospice and dying there, but only after longer in an ICU and more back and forth between care settings than ever before. As Teno says, this one day of hospice may be seen by the patient and family as beneficial and gives the patient the chance to “die in peace”- not an insignificant outcome. And maybe this is what many people mean when they say in surveys that they want to die at home. Maybe they mean that they want to keep using aggressive care right up to the end and then go to hospice to die- although even in this scenario the rise in ICU use is hard to understand. If that is, in fact, the preference of these patients, that is fully consistent with modern palliative care practice.

However, this reality is a little hard to believe. Certainly there will be occasional people who will choose this course- but so many? My fear is that for some patients the medical team is holding off having real goals of care discussions until death is imminent. I hear complaints fairly frequently from palliative care teams and hospice teams that referrals come to them much later than they would prefer. Health care chaplains have long had the same lament. It will be interesting to see if the increasing penalties for readmissions and new regulations, such as in New York State, which require patients with less than six month to live be informed of the option for hospice and palliative care will make a difference.

Until then, is it good that more people are dying at home? Given the results repeatedly expressed in surveys, probably so. But Teno’s work reminds us that there is likely a lot more work to be done until we get to the point where every patient and family is included in their care planning from the beginning of their treatment process, all options for treatment and sites of care are explored, and the number of people who are at the end of life but still transitioning in and out of ICUs better aligns with what patients and families seems to be saying they want.

George Handzo, BCC, CSSBB
President, Handzo Consulting
Senior Consultant, HealthCare Chaplaincy

Shaping the Future – a Member-Driven Campaign

I know the Academy well.

The Academy has been an important force in raising the professionalism of hospice and palliative medicine, and also getting it more into mainstream medical thought and practice.

The more we enhance the professionalism and practice of hospice and palliative care physicians, the better our patients will be cared for. The more hospice care is present in the daily lives of patients and doctors, the more the healthcare system and patients will benefit. It’s important to advocate for this.

That’s why I donated to the Shaping the Future campaign. I know that contributions get used in a variety of ways, including educational activities, advocacy, and workforce expansion. Rather than restrict my donation to a particular area, I trust the existing leadership to use my gift in the best way possible.

Join close to 200 of your colleagues by making your donation to the Shaping the Future campaign today. Visit www.aahpm.org and click “Donate Now” on the home page to make your one-time donation or multi-year pledge. Your generosity will help expand the workforce, deliver innovative education, and facilitate effective advocacy.

David McGrew, MD FAAHPM, who currently serves as president of Hospice & Palliative Physician Services, LLC, and Chief of Medical Staff at HPH Hospice, Inc. is a founding member, a board member for about 12 years, and a past president.

Education Resource Email #3: AAHPM’s Capitol Hill Days

In the interest of archiving the Education SIG’s “Education Resource Email” collection and making it more widely available, we have decided to post past emails. The email below was originally sent to the Education SIG listserve on November 21, 2012.
—————-
Capitol Hill Days and advocating for education funding

Dear Education SIG colleagues,

In the midst of your travel and/or preparation for the Thanksgiving holiday, I hope you can find time to read the following resource describing my experience at AAHPM’s Capitol Hill Days. I hope that it will offer some additional perspective on how both our SIG and the individuals therein might advocate for eduation funding. Most importantly, there is action that you can take today to help move this effort forward, so keep reading (or at least flag for follow-up when you return to work)!

I attended AAHPM’s Capitol Hill Days on behalf of our Education SIG this past July 16-18. I thought it might be useful to provide you with some information about what I learned during that experience and what it was like as a way of encouraging some of you to participate in Capitol Hill Days in future years.

Over the last few years, AAHPM has worked to craft a bill, entitled the Palliative Care and Hospice Education and Training Act (PCHETA), aimed at expanding opportunities for interdisciplinary education and training in palliative care and to secure support for its introduction in Congress. Specifically, PCHETA has 5 major aims:

1. Establishes Palliative Care and Hospice Education Centers to improve the training of interdisciplinary health professionals; develop and disseminate palliative care curricula; support training and retraining of faculty; provide students with clinical training in appropriate sites of care; and provide traineeships for advanced practice nurses.

2. Provides for physician training by authorizing grants to schools of medicine, teaching hospitals, and GME programs to train physicians (including residents, trainees, and fellows) who plan to teach palliative medicine.

3. Establishes Academic Career Awards to promote the career development of BC/BE junior faculty physicians in HPM. Eligible individuals must provide assurance of a full-time faculty appointment in a health professions institution and commit to spend a majority of their funded time teaching and developing skills in interdisciplinary education in palliative care.

4. Emphasizes workforce development by authorizing funding for up to 24 Palliative Care and Hospice Education Centers to establish fellowship programs that provide short-term intensive courses focused on palliative care. These fellowship programs will target current faculty who do not have formal training in palliative care and will provide formal re-training of these mid-career physicians in palliative medicine.

5. Provides career incentive awards for eligible health professionals who agree to teach or practice in the field of palliative care for at least 5 years. Eligible individuals include: advanced practice nurses, clinical social workers, pharmacists, and psychologists who are pursuing a doctorate or other advanced degrees in palliative care or related fields.

Sounds pretty great, right? Our visit to the Hill was timed to coincide with the week of this bill’s introduction on both the House and Senate floors. We began on Monday evening, July 16, with a working dinner where we were briefed on the bill and its potential impact on our field. We were lucky enough to have Senator Ron Wyden (D-OR), the primary sponsor of the bill, come to speak with us about his personal interest in this bill and about how we could be helpful to the cause in our upcoming meetings with other senators, representatives, and their staff members.

Tuesday morning, we learned about the legislative process and heard from various groups who are present throughout the year on the Hill working to advance issues related to hospice and palliative care. This was followed on Tuesday afternoon by highly coordinated visits with our local senators and representatives and/or members of their staff. In my case, I met with Legislative Assistants (LAs) for both of my state senators from North Carolina and with my own local representative, Rep. David Price (D-NC).

These experiences on Tuesday afternoon were clearly the highlight of the trip. We were understandably somewhat nervous as we entered the Senate and House office buildings, going through metal detectors and finding our way to the appropriate office replete with the state flag positioned outside the door. Luckily, we were accompanied by one of the staff members from the lobbying organization which supports AAHPM. They were there to ensure that we knew what to say (and what not to say) and also to debrief with us after our meetings. When meeting with legislative assistants, the staff member’s knowledge of the bill could vary from none to a modest amount. We often found ourselves explaining the difference between hospice and palliative care and highlighting the workforce issues in our field, especially as the population ages and becomes ever sicker. All in all, much of the interaction was not that different from talking with a patient or family member in our clinical setting. And who better to communicate about our field than one of us?! That, of course, is the impetus for these Capitol Hill Days.

The day after our visit, on July 19, 2012, AAHPM’s efforts came to fruition when the Palliative Care and Hospice Education and Training Act (PCHETA) was introduced in the United States Congress. PCHETA was introduced as S.3407 in the Senate by Sen. Ron Wyden (D-OR) and as H.R.6155 in the House by Representative Eliot Engel (D-NY17). As a result of our group’s collective efforts that week as well as ongoing efforts by AAHPM members and our lobbying group, the bill now has 38 co-sponsors in the House and 6 co-sponsors in the Senate.

As we learned during our time on the Hill, the introduction of PCHETA and gaining the above co-sponsors does not indicate that our work is done. In fact, just this week, those of us who attended Capitol Hill Days are following up with the staffers with whom we met in July. Any additional co-sponsors that we can gain during this lame duck session are very important as this support is very likely to carry over when the bill is re-introduced next year.

So, what can you do? If PCHETA sounds great to you, please visit the AAHPM Legislative Action Center at http://www.capwiz.com/aahpm/home/ and take the time to contact your senators and representative. It doesn’t take long but it will go a long way towards this bill gaining traction leading in to the next Congress. Think of it as your way of giving thanks for the work that AAHPM elected leaders and staff members do on our behalf year-round for our field and its practitioners.

Overall, I found Capitol Hill Days to be a great opportunity to learn more about AAHPM’s policy agenda and advocacy efforts and to network with other AAHPM members interested in advocacy on the part of AAHPM and our field. If you have any questions about ths experience, I’d be more than happy to speak with any of you about it.

Best wishes to you all for a Thanksgiving spent with family or friends or doing good work for patients and families,
Lynn

Lynn O’Neill, MD
Duke Palliative Care
Assistant Professor, Division of Geriatrics
Duke University School of Medicine
DUMC Box 2706, Durham, NC 27710
Telephone 919-668-7215 ~ Fax 919-684-0572
lynn.oneill@duke.edu

Education Resource Email #2: Harvard Macy Institute

In the interest of archiving the Education SIG’s “Education Resource Email” collection and making it more widely available, we have decided to post past emails. The email below was originally sent to the Education SIG listserve on July 13, 2012.
—————————
Hi everyone,
Two of your fellow EdSig members, Jennifer Reidy and Holly Yang, have taken the time to describe their experience at the Harvard Macy Institute faculty development course. Please keep reading as this is an amazing resource!
Best,
Lynn O’Neill
Education SIG Vice-Chair

Dear Education SIG members,

This year we’ve attended courses at the Harvard Macy Institute in Boston, which we want to highly recommend as an outstanding resource for faculty development. The Program for Educators in Healthcare Professions is designed for physicians, basic scientists and other healthcare professionals to stretch their skills in teaching, curriculum development, evaluation, leadership and information technology. The program consists of two sessions in residence at Harvard: an 11-day winter session and a 6-day spring session. Throughout the program and between the sessions, participants conduct an educational project of their own design at their home institution with support from peer and faculty mentors at Harvard Macy.

We had a class of about 80 people from 13 countries, and made invaluable friendships and professional relationships. The course director, Dr. Liz Armstrong, designed the course to foster a strong sense of community. The experience is very rigorous and intense, and you feel bonded to your classmates – likely for the rest of your careers. It is a great opportunity to network outside of palliative medicine and introduce our field to influential peers in medical education.

All of us have been to innumerable conferences during our education and careers, but Harvard Macy is truly a transformative, life-altering experience! The faculty are among the best we’ve ever seen, and they come from Harvard’s schools of medicine, business and graduate education. As a result, the curriculum is a fascinating mix of educational theory, adult developmental psychology, literature on organizational change and quality improvement, among other themes. One of the highlights of the course is the “peer consultation group,” which consists of 4-5 participants and a faculty facilitator who brainstorm ideas, give advice and provide support for each individual’s educational project throughout the course and beyond. We intend to keep in touch with our groups and will likely seek feedback from them for years to come.

For more details, you can check out their website at harvardmacy.org. The program is expensive and requires a significant time commitment, so getting support from your own institution is paramount. There are a growing number of alumni who are palliative care physicians, so we are creating our own community as well! Please feel free to contact us if you have questions or want more information.

Cheers,

Jennifer Reidy, MD
University of Massachusetts
Jennifer.reidy@umassmemorial.org

Holly Yang, MD
San Diego Hospice & Palliative Care
hyang@sdhospice.org