Paper Calls on Family Physicians to lead EOL Conversations:

  • “Right place, right time: facilitating end-of-life conversations” appears in Journal of Family Practice. The document is a guide that “offers tips and resources to help family practice physicians engage in end-of-life conversations that address patients’ needs and reduce the burden on friends and family. The guide notes that, with the increased geriatric population, “the lines between improving the length of life vs improving its quality” are making end-of-life (EOL) conversations increasingly important. This includes advance care planning, honoring patients’ wishes, and improving end of life care.
  • These important EOL discussions, says the guide, should start with family physicians where relationships are ongoing between physicians and patients. The guide/article focuses on facing the challenges in doing this and offers guidance and support to family physicians.
  • “As many as 90% of patients with a life-threatening illness report never having discussed EOL care issues with their clinician.” Engaging patients in advance care planning (ACP) is important, and yet many physicians have not been trained to do this. So education for providers is important. Often, patients wait for their physicians to open these conversations, and the article provides opening questions that can be used by physicians. Physicians are encouraged to normalize these conversations.
  • The article encourages family doctors to use CMS billing codes to provide time for these discussions. These early discussions have a positive outcome for families, as patients who have engaged in these discussions elect palliative and hospice care sooner. The article reports outcomes of a Dutch study that further quantifies the value of these early EOL conversations. The paper refers physicians to several resources on strengthening these conversations, including “VitalTalk and the ABCDE plan.”
  • Next, the paper offers help to physicians in “how to navigate EOL discussions with patients with dementia,” especially encouraging that EOL discussions begin as soon as possible. They paper cites one NIH study that found “that people with mild-to-moderate dementia . . .are able to participate meaningfully in EOL discussions and ACP.” Numerous other tools are noted and described.
  • By making palliative care available, initiating EOL conversations, and engaging surrogates in the process, quality of life is improved. These EOL conversations, says the paper, will help physicians support patients and surrogates, and “have a positive impact on many clinical outcomes.” (Journal of Family Practice, https://cdn.mdedge.com/files/s3fs-public/JFP07103074.PDF )

 

“Losing a Loved One Can Be Life-Threatening.”

  • A study, reported in JACC: Heart Failure finds evidence that “losing a loved one isn’t just painful: it can also be life-threatening.” Swedish researchers reviewed records of heart failure patients, over a period of four years, who died from heart failure between 1987 and 2018. They found that those who had lost a family member were “significantly more likely to die over that time period compared to those who had not lost a loved one.” Time magazine covers the study in an article titled “Losing a Loved One Can Be Life-Threatening.”
  • These deaths during bereavement are mostly due to heart failure. When losing a spouse, increased risk of death was 20%, while a death following the loss of a child was 10%, and the death of a sibling increased death risk by 13%. The loss of a parent did not increase risk of death. But, the risk increased even more for those who lost two loved ones.
  • The risk was highest during the first week, with a 78% increased risk of dying compared to those not grieving, and “a 113% increased risk over the first eek if the person had lost a spouse or partner.” This high risk continues for several weeks and during the entire first year of loss.
  • Researchers were “somewhat surprised” that the loss of a spouse increased death risk more than the loss of a child. But, they note, more of the patients were older, with an average age of 79, and the loss of a spouse/partner may “‘impact the quality of life much more.’”
  • Krisztina Laszlo, co-author of the study, says that the negative changes that leads to these deaths shows how much grief “affects the nervous and neuroendocrine systems. . .” Sometimes behavioral changes, such as “drinking more and exercising less,” add to the problem.
  • While more research is needed, “the study is a reminder for family members and health care providers that people need increased support after losing a loved one.” Loss can be profound, and says Laszlo, “Death is just the tip of the iceberg. It denotes there is serious suffering.” (JACC: Heart Failure, 7/6, https://www.jacc.org/doi/abs/10.1016/j.jchf.2022.05.005; Time, 7/8, https://time.com/6195183/losing-loved-one-heart-risk)

 

HOSPICE NOTES

Trella Health examines how beneficiaries adhere to discharge instructions that advise they go to hospice, skilled nursing, or home health. Their findings show that 10% of those “instructed to enter hospice care were not admitted to a hospice agency within 30 days of inpatient care.” And 30% of patients who were referred to home health did not access those services either. This lack of follow-through  during transition suggests, says the report, that “referral partnerships with facilities in a PAC agency’s market can increase adherence rates, resulting in lower readmission rates for patients discharged from an inpatient stay.” For hospices and home care agencies, the message is clear: “continue to build referral relationship with inpatient facilities to increase adherence rates to post-acute discharge instructions.”(Trella Health, 5/3, https://www.trellahealth.com/hospital-discharges-post-acute-cares-adherence/)

“Hospice Insights: The Law and Beyond,” offered by Husch Blackwell, offers a new podcast in their series. The podcast, “Beyond Hospice: The OIG Renews Its Scrutiny of Home Health Agencies,” says that home health, like hospice, is “receiving significant government scrutiny.” The podcast explores this, and is available online at the link below. (Husch Blackwell, 7/6, https://www.huschblackwell.com/newsandinsights/beyond-hospice-the-oig-renews-its-scrutiny-of-home-health-agencies)

A recent study published in Healio News is titled, “Death in hospice facility less common among rural vs. urban residents with blood cancer.” The study found that blood cancer deaths of patients within a hospice facility in 2019 were 8.6% in rural areas; 15% in small/medium metro areas; and 12.8% in large metro areas. Study researchers says these findings “suggests individuals with hematologic malignancies are not receiving the best possible end-of-life care. .”  Next, the researchers will “explore geographic disparities in mortality and end-of-life care” on county and state levels and look for obvious gaps. (Healio News, 6/30, https://www.healio.com/news/hematology-oncology/20220629/death-in-hospice-facility-less-common-among-rural-vs-urban-residents-with-blood-cancer )

 

PALLIATIVE CARE NOTES

A study published in Journal of Pain and Symptom Management examined the “Effect of a Collaborative Palliative Care Intervention vs Usual Care on Quality of Life of Patients with Symptomatic Heart and Lung Diseases.” The researchers set out to examine “a collaborative palliative care intervention” and determine if this improves quality of life for a subgroup of patients including COPD and chronic heart failure patients. The links below reviews the methods, and reports that the early palliative care intervention did indeed improve quality of life for these patients. (Journal of Pain and Symptom Management, 6/1, https://www.jpsmjournal.com/article/S0885-3924(22)00494-8/fulltext;  https://www.jpsmjournal.com/article/S0885-3924(22)00494-8/pdf)

An article in American Nurse explores “COVID-19 and palliative care.” The article provides an overview of some of the challenges in the pandemic. Specific attention is given to defining palliative care, naming six essential components of palliative care, and “U.S. palliative care recommendations.” The author then turns attention to how palliative care has been applied during COVID. Nurses “can promote early integration of palliative management…to reduce symptom burden, prevent exacerbation of underlying conditions, avoid hospitalization, and maintain physical functioning and quality of life.” (American Nurse, 7/6, https://www.myamericannurse.com/covid-19-and-palliative-care/ )

Medpage Today offers “‘Don’t Let Me Die in Pain,’ My Patient Pleaded.” Palliative care physician Ramandeep Kaur shares about caring for a young terminally ill woman with metastatic pancreatic cancer. She was suffering with tremendous pain and begged him to not let her die in pain. Kaur say that the patient’s chart was marked “‘NO IV OPIOIDS’” due to her having a history of injecting heroin. Kaur reflects on the difficulty of facing this patient’s need, and  physicians’ fear of prescribing strong pain relievers – especially in a case like this. Kaur asks, “Do they deserve to die in pain because they suffered from addiction to illegal substances?” A palliative care team, says Kaur, has an ethical responsibility to care for patients and “relieve their suffering to the best of their ability. . .” Providers must address the suffering and deal with patient’s needs. (Medpage Today, 7/9, https://www.medpagetoday.com/opinion/second-opinions/99643)

 

END-OF-LIFE NOTES

“Art, Drama, and a Terminal Illness” appears in Medpage Today. The article tells a story of Ellen Dunphy, an actress and playwright. In 2020 ,when she was a healthy young adult, Dunphy met physician Tyler Johnson. Together, the two made a teaching video instructing physicians “how to discuss terminal illnesses with patients.” Merely six-months later, however, Dunphy was diagnosed with terminal gastric cancer, and Johnson became her personal oncologist. A podcast in “The Doctor’s Art” series now offers. a podcast that shares Dunphy’s experiences in learning about her diagnosis and dealing with grief. The first link below offers a transcript of that podcast. Her experiences have led her to create a play about her cancer journey. The one-woman play, “Imaginary Endings,” is online at the second link below. (Medpage Today, 6/28, https://www.medpagetoday.com/podcasts/thedoctorsart/99461; YouTube, https://www.youtube.com/watch?v=MswEe-XYPQ4&ab_channel=Ellen)

“When Too Much Treatment Creates More Harm Than Good” appears in Medscape. The article examines care for patients with ovarian cancer. Though clinical guidelines  advise “against intensive or invasive end-of-life care, more than half of woman with terminal ovarian cancer receive at least one aggressive intervention,” according to an earlier study published in JCO Oncology Practice. Author of the Medscape Today article, Megan A. Mullins, PhD, MPH, notes the “disconnect between what people think aggressive care might do” and what it actually does. Often, the continuing interventions lead to “not being admitted to hospice (28.9%), receiving an invasive procedure (20.7%) and being admitted to an intensive care unit (18.6%). Mullins also says, that while end-of-life conversations may be difficult, there is “evidence to show that these conversations don’t actually reduce patients’ hopes…” The earlier JCO Oncology Practice article concluded that improving the quality of care of these patients “should include interventions aimed at physician practices and decision making in end-of-life care. The first link below leads readers to the Medscape article and the second link goes to the earlier JCO Oncology Practice article. (Medscape, 7/8, https://www.medscape.com/viewarticle/976778#vp_2; JCO Oncology Practice, 2021, https://ascopubs.org/doi/abs/10.1200/OP.21.00351)

Scientific American offers “Two Cancer Patients Battle to Make Psilocybin Accessible for Palliative Care.” The article explores the value that psilocybin therapy offers to terminally ill persons. The use of this therapy, however, is not approved by the FDA. The 2018 Right to Try Act “permits people with life-threatening illnesses to try investigational drugs that have made it past phase 1 clinical trials.” Sunil Aggarwal, a palliative care physician at the Advanced Integrative Medical Science (AIMS) Institute in Seattle, has two patients she believes might benefit from this therapy. A legal effort is “seeking to compel the DEA to open access to psilocybin under Right to Try laws,” but has thus far been unsuccessful. The article shares some of the history and positive outcomes of using psychedelic drugs. Three clinical studies that began as early as 2011, “found that psilocybin therapy produced mood-elevating effects and that the benefits lasted weeks or even months following a single active-treatment session.” Phase III  trials are now necessary. (Scientific American, 7/8, https://www.scientificamerican.com/article/two-cancer-patients-battle-to-make-psilocybin-accessible-for-palliative-care/)

 

GRIEF NOTE

Oprah Daily offers “The Stages of Grief Explained and How to Cope With Loss.” The article notes that grief is individual and that there are no timelines. Elisabeth Kubler-Ross’s five stages of grief are noted and explained, and says, “The American Psychological Association describes the five stages as ‘a hypothetical model. . .’” The article recommends specific books, journaling, and engagement in activities that bring joy. (Oprah Daily, 7/7, https://www.oprahdaily.com/life/relationships-love/a40514715/stages-of-grief/)

OTHER NOTE

On July 6, FBI issued jointly, along with the Cybersecurity and Infrastructure Security Agency and the Department of the Treasury, a security advisory warning about “ransomware against the U.S. health care and public sectors.” FBI says “the threat stems from the North-Korean state-sponsored cyber actions since at least May 2021…” The advisory details items about the threat, offers technical details, names “Indicators of Compromise,” and offers ideas about preparing for ransomware. Further resources are also offered. (CISA.gov, 7/6, https://www.cisa.gov/uscert/sites/default/files/publications/aa22-187a-north-korean%20state-sponsored-cyber-actors-use-maui-ransomware-to-target-the-hph-sector.pdf; Becker’s Hospital Review/Becker’s IT, 7/6, https://www.beckershospitalreview.com/cybersecurity/north-korea-backed-ransomware-targets-healthcare.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=4546C5822612C9X)

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Hospice Analytics is the national sponsor of Hospice News Network for 2022. Hospice Analytics is an information-sharing research organization whose mission is to improve hospice utilization and access to quality end-of- life care. For additional information, please call Dr. Cordt Kassner, CEO, at 719-209-1237 or see www.HospiceAnalytics.com.