MEDICAL SCHOOLS CAN BETTER PREPARE PROVIDERS TO “FACE THE VOID WITH OUR PATIENTS”
“Why Don’t Medical Schools Prepare Us to Face the Void With Our Patients?” This question is the title of an article in Science The Wire, and the article appeared first in The MIT Press Reader. Authors of the article are physicians Nicole M. Piemonte, Assistant Dean for Medical Education at Creighton University School of Medicine in Phoenix, and Shaw Abreu, a hospice and palliative care physician. The two have also written together the book “Death and Dying.”
The article examines the lack of medical training offered to help physicians care for people near life’s end. Physicians are left, they say, to make judgement calls at the end of patients’ lives. The decision, often, is to “do more,” and the result is unneeded suffering and unhelpful interventions at life’s end.
The article describes, through patients’ experiences, some of the difficulties of this decision-making. Physicians recall times that they were amazed by patients regaining health by these unlikely-to-succeed interventions, and times when they felt guilty about offering care that caused suffering. They call this desire, to continue life at all costs, the “rescue fantasy.”
They explore the use of CPR and the data on successful outcome from this intervention. Of all who receive CPR, they say, about 15% to 20% actually walk out of the hospital. And that number is much less for patients with increased age and illness. An ill person with cancer, for example, has a 2.2% chance of walking out of the hospital. Many end up with broken ribs and poor quality of life, and “only 3-7% of patients [are] able to return to their previous level of functioning after experiencing CPR in the hospital.”
The article examines the difficulties of locating advance directives, and responding to family requests for interventions. In spite of expert leaders and authors in end-of-life care, says the article, “the principles guiding hospice and palliative medicine – whole person care, comfort and quality of life – have not penetrated mainstream medicine.” Before this can happen, says the article, providers will need to sideline the ”rescue fantasy and face uncertainty together.” To really support people as they die is a big calling. “Can we imagine people not only dying in ways consistent with their goals, but also having expert medical guidance, physical comfort, emotional validation, and spiritual meaning-making every step along the way?” Instead, too often, we leave patients with a bleak and abandoned experience, saying, “There is nothing more we can do.” (The MIT Press Reader, https://thereader.mitpress.mit.edu/reckoning-with-medicines-rescue-fantasy/; Science Wire, 2/6, https://science.thewire.in/health/why-dont-medical-schools-prepare-us-to-face-the-void-with-our-patients/)
AUTHOR EXPLORES “THE GRIEVING BRAIN”
Mary-Francis O’Connor, author of “The Grieving Brain,” explores how our brains deal with losing someone we love “and how to heal.” “When a loved one dies,” says O’Connor, “your brain is trying to solve a problem.” She shares the experience of feeling that we don’t know where someone is after they die. We know cognitively that a person has died, but it often happens, O’Connor says, that we may not fully integrate this reality as our brains learn “this is a whole new world.”
O’Conner is an associate professor of psychology at the University of Arizona and director of their Grief, Loss and Social Stress (GLASS) lab. Her PhD work was followed by a year’s fellowship “in psychoneuroimmunology the UCLA Semel Institute for Neuroscience and Human Behavior.”
Grieving, says an article in Today on O’Connors’ writing, is a type of learning as our brains try to solve the problem of old patterns of being together that have suddenly changed. Grief is not like depression. “The core feeling in grief is yearning, with a specific person as its object.” And, she notes, most of us have resilience that allows us to be restored to a meaningful life. About 10% experience “complicated or prolonged grief” where suffering is more severe.
When you lose someone you love, “your brain needs to update its virtual map of the world.
It doesn’t happen quickly. “Your loved one is not gone—they are in your brain.” Neuroscientists say that significant loving relationships create “changes in neural connections.” And when death separates us, that encoding does not go away.
Literary Hub features an article about O’Connor titled “On the Persistence of Magical Thinking in the Face of Grief.” As the brain’s works to integrate the reality of death of a loved one, old patterns of the loved one presence are still with us as well. She speaks of Joan Dideon’s book, “The Year of Magical Thinking.” Dideon shares that she couldn’t get rid of her husband’s shoes for a year, because “‘he might need them again.’” Again, she says, this paradoxical thinking is found in the “neural systems of our brain, systems that produce different aspects of knowledge and deliver them to our consciousness.”
Experiences of bereaved persons demonstrate that “the brain can persist in two mutually exclusive beliefs.” We know someone we love has died – and we believe, on another level, that they will return. “If a person we love is missing, then our brain assumes they are far away and will be found later.” (Today, 1/26, https://www.today.com/health/mind-body/grief-changes-brain-rcna13613; Literary Hub, 2/7,
https://lithub.com/on-the-persistence-of-magical-thinking-in-the-face-of-grief/; Spirituality & Health, 12/22/2021 https://www.spiritualityhealth.com/reviews/books/2021/12/22/book-review-the-grieving-brain )
* Husch Blackwell has posted their podcast on “Exploring Answers to Hospices’ Top Vaccination Questions.” The attorneys examine the COVID-19 vaccination issues and offer guidance for full compliance. The webinar is online at the second link below
(Husch Blackwell, 2/4, https://www.healthcarelawinsights.com/2022/02/exploring-answers-to-hospices-top-vaccination-questions/?utm_source=Husch+Blackwell+-+Healthcare+Law+Insights&utm_campaign=bc383aa932; Husch Blackwell, https://bit.ly/3L4nSOV)
* “Four Florida Hospice and Palliative Care Organization Form Synthase Collaborative.” So reads the headline of a PR Newswire release. The hospices include Avow, Haven, St. Francis Reflections Lifestage Care, and Treasure Coast. Synthase Collaborative is a nonprofit corporation focused on helping “to achieve economies of scale and ensure patient satisfaction and quality care. “‘This partnership,’” says the release, “‘will also strengthen our position to negotiate with insurers as new value-based payment models emerge, which supports our mission to enhance access to compassionate hospice and palliative care as well as other post-acute and home-based care in the communities we serve.’” (PR Newswire, 2/8, https://www.prnewswire.com/news-releases/four-florida-hospice-and-palliative-care-organizations-form-synthase-collaborative-301477496.html)
* VA offers a Home-Based Primary Care Program (HBPC) that cares “for seriously ill or disabled Veterans who wish to age in place, at home.” A VA study reveals “family members were happier with HBPC when it was combined with community-based hospice services at the end of life.” An aftercare survey of families of decedents shows that families whose deceased loved one received hospice are more satisfied than those who had no hospice Pain management was the one noticeable exception. When comparing outcomes for those served by hospices vs. those who were not served by hospices, the results were:
- “Providers are always kind, caring, and respectful—87.7% vs. 84.7%
- Received adequate management of PTSD symptoms—84.4% vs. 84.7%
- Received spiritual support prior to death—61.6% vs. 54.8 %
- Were informed about survivor benefits—39 % vs. 35.2%
- Received adequate pain management—29.9% vs. 38.7%”
(VA Research Currents, 2/7, https://www.research.va.gov/currents/0222-Survey-uncovers-family-perceptions-on-end-of-life-care-for-Veterans.cfm)
* Delta Care Rx, recognizing hospices’ staffing challenges during the pandemic, are offering “free access to a suite of essential Remote Patient Care and Telehealth tools.” The tools are available to hospices that have a “publicly available mission statement and/or mission-driven goals and initiatives.” More information is online at the link below. (PR Newswire, 2/9, https://www.prnewswire.com/news-releases/as-staffing-challenges-continue-for-hospices-delta-care-rx-offers-free-remote-patient-care-tools-301477605.html)
* CMS posts “Getting Started with Hospice CASPER Quality Measure Reports: February 2022.” The fact sheet provides information to hospices about the two CASPER Quality Measure reports and offers a “potential model hospices could employ to use the QM reports for quality improvement.” (CMS, https://edit.cms.gov/sites/default/files/2022-02/Getting_Started_with_HQRP_CASPER_QM_Reports_Feb_2022.pdf)
* An article in MedCityNews proclaims the value of hospice for improving care for patients, And, when “correctly deployed,” hospice care often provides “major reductions in unnecessary utilization and significantly decreases medical costs. To offer hospice care that is most efficient, says the article, “many provider groups are implementing predictive analytics to help them evaluate and understand their options around end-of-life care and hospice programs.” The article is written by Jacob Hochberg with Arcadia, a firm that “transforms date from disparate sources into targeted insights.” The approach leads them to conclude that hospice patients who spend 10 or more days n hospice “died more comfortably with minimal intervention in their final days of life.” The article explores ways that hospices can use this data analysis. It explores pre-program assessment, the identification of patients most likely to benefit from hospice care, and the targeting of physicians to offer additional education,” (MedCityNews, 2/9, https://medcitynews.com/2022/02/using-analytics-for-compassionate-end-of-life-care/)
* Randy Voepel (R) serves on the California State Assembly and introduced a bill that is “An act to amend Section 17552 of, and to add Section 1751.200 to, the Health and Safety Code, relating to hospice.” The new section that is proposed to be added to the bill would go beyond Medicare requirements and require recertification to be “conducted by at least one physician in conjunction with the medical director of the hospice or the physician member of the interdisciplinary group.” The current law would also be changed to require hospice surveys every three years, and for the results of the surveys to be “made available to the public, to the extent consistent with federal and state privacy laws.” (California Legislative Information, 2/8,
PALLIATIVE CARE AND END-OF-LIFE NOTES
* Journal of Palliative Medicine shares “Generalist versus Specialist Palliative Medicine.” The discussion centers on forward-looking discussion about the work of palliative care. The online article features a transcription of a discussion about palliative care. The discussion includes palliative care leaders Vyjeyanthi S. Periyakoil and Charles F. von Gunten who serve as moderators, and Stacy Fischer Steve Pantilat, and Timothy Quill. (Journal of Palliative Medicine, 2/3,
* End of Life University has posted a podcast titled “The Hospice Doctor’s Widow: A Caregiver’s Journal with Jennifer O’Brien.” O’Brien’s husband, who was a hospice and palliative care physician, died from cancer. In the podcast, she shares about her journey as a caregiver, about grief and loss, and about “precious time.” (End of Life University, 2/7, https://eolupodcast.com/2022/02/07/ep-337-the-hospice-doctors-widow-a-caregivers-journal-with-jennifer-obrien/)
GRIEF AND ADVANCE CARE PLANNING NOTES
* Koda Health, based in Houston, focuses on digital advance care planning. Now, having raised $3.5 million in “its latest seed round,” the company plans to double the size of its staff within six months. They plan to expand to serve all states and “to focus on low-resource communities and operating in different languages.” More information is online at the link below. (Innovation Map, 2/9, https://houston.innovationmap.com/koda-health-tatiana-fofanova-seed-funding-2656600089.html)
* “What ‘Shared Death Experiences” Are & Why We Need To Discuss Them” is an article in mindbodygreen. The article explores the experience of people “accompanying their friend or loved one part way on their journey out of earthly life.” (mindbodygreen, 2/8, https://www.mindbodygreen.com/articles/shared-death-experiences)
* CAPC offers open access to a compendium of tools that enable organizations to respond to COVID-19. The tools relate to and include: communication, symptom management, emotional PPE, palliative care team, telehealth, waivers, home and long-term health, patients and families, health equity, end of life and FAQs. (CAPC, https://www.capc.org/covid-19/)
* “Top Trends in Tech-Enabled Home Care,” posted by Foley and Lardner LLP, offers insights from the HC100 Conference held recently in Phoenix. The article reports on the responses by healthcare providers to “boomer health care needs, nursing shortages, and competitive career paths of younger people.” The increased use of technology is quickly emerging as a major driver of change in care. “Integrating primary in-home care with home heath, palliative care and hospice—especially for complex patients—has been a winner to date.” The article is available at the link below. (Foley and Lardner LLP, 2/13, https://www.foley.com/en/insights/publications/2022/02/top-trends-in-tech-enabled-home-care)
* CDC has proposed new guidelines for opioid painkiller prescribing. The proposed guidelines, while encouraging nonopioid treatments to the extent possible, say physicians, when prescribing opioids, should “use their best judgement.” The 12 recommendations, still in draft form, “are the first comprehensive revisions of the agency’s opioid prescribing guidelines since 2016.” The proposed guidelines, says the president of the American Society of Regional Anesthesia and Pain Medicine, are “‘a total change in the culture from the 2016 guidelines.” The recommendations are on the Federal Register, at the second ink below, and are open for public comment for 60 days. CDC will consider the comments and hopes to have a final version by the end of 2022. Patient advocates expressed positive response to the proposed guidelines. The executive director of the National Pain Advocacy Center says, “‘We went from one side of the pendulum, with overly liberal prescribing of opioids and that did harm, to just looking at gross drops in prescribing without looking at individual needs And that did harm.” Of note, “the guidelines do not apply to patients suffering pain from cancer or sickle cell, or in end-of-life or palliative care. The third link below is CDC’s information on the process and new guidelines. (New York Times, 2/10, https://www.nytimes.com/2022/02/10/health/cdc-opioid-pain-guidelines.html; Federal Register, 2/10, https://www.federalregister.gov/documents/2022/02/10/2022-02802/proposed-2022-cdc-clinical-practice-guideline-for-prescribing-opioids; CDC, https://www.cdc.gov/opioids/guideline-update/index.html)
Thanks to Marisette Hasen for contributions.
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