Category: Health Care

Covering news of the delivery, service, industry, research, policy, and finance of health care as it pertains to end of life issues.

Unreasonable optimism among physicians common during end of life care

Unreasonable optimism among physicians negatively impacts patients’ end of life care- often influencing the terminally ill to accept more aggressive, costly treatments with little chance of effectiveness.

Image: Wikimedia Commons
Image: Wikimedia Commons

Haider Javed Warraich,  a resident of internal medicine at the Beth Israel Deaconess Medical Center, recounts his optimism when he first met a woman suffering from heart failure and a condition preventing blood from flowing out of her heart.

“While learning her medical history, I also got to know her,” Warraich writes. His patient was a 50 year-old former artist, derailed by addiction. “At this point, she wasn’t a suitable candidate for heart surgery. But I felt there was still hope,” he recounts in The New York Times Sunday Review.

With perseverance, Warraich convinced his colleagues to order a procedure called alcohol septal ablation. Though the procedure could potentially reduce her symptoms, it came with many risks. His patient died the next day, after a complete heart block and aggressive attempts to revive her.

Warraich explains that he was victim of “irrational optimism, a condition running rampant in both doctors and patients, particularly in end of life care.” These physicians may push for costly and more aggressive treatments as a last resort, even when there is little hope of recovery.

As a study published in 2000 for the British Medical Journal shows, about two-thirds of doctors overestimate the survival of terminally ill patients. ”Doctors are inaccurate in their prognoses for terminally ill patients and the error is systematically optimistic,” concluded the researchers, headed by Nicholas A. Christakis, then of the University of Chicago.

Many times, those poor estimates are never fully communicated to the patient. A 2001 study of cancer patients published in the Annals of Internal Medicine found that physicians only told patients their estimated survival 37 percent of the time. No estimate was given 23 percent of the time. “Around 70 percent of the discrepant estimates were overly optimistic,” Warraich notes.

A 2012 study published in the Journal of Clinical Oncology found that cancer patients who talk with their physicians about how they want to die are less likely to opt for aggressive end of life treatments in the last two weeks of life, and they have much more comfortable deaths.

“Aggressive care at the end of life for individual patients isn’t necessarily bad, it’s just that most patients who recognize they’re dying don’t want to receive that kind of care,” said lead author Dr. Jennifer Mack of Harvard University Medical School.

Similarly, Warraich suggests more palliative care for patients unlikely to survive a serious illness. “Modern palliative care originated in response to the proliferation of new treatments and resuscitation technologies,” he writes. Palliative care not only provides more comfort alongside standard treatments, but it has been shown to help patients live a little longer.

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Community cancer clinics turning thousands of patients away

Image: Flickr, TipsTimes via Creative Commons,
Image: Flickr, TipsTimes via Creative Commons,

Many U.S. cancer clinics have started to turn away thousands of patients due to the sequester’s cuts to Medicare.

As The Washington Post’s Sarah Kliff reports, some oncologists say the reduced federal funding makes it impossible for community clinics to administer expensive chemotherapy to seniors and remain financially stable. These patients must now seek treatment elsewhere, even as hospitals accepting Medicare beneficiaries grow more overcrowded.

Jeff Vacirca, chief executive of North Shore Hematology Oncology Associates in New York, told Kliff, “If we treated the patients receiving the most expensive drugs, we’d be out of business in six months to a year.” Vacirca said his clinics have stopped administering drugs on which they lose money. His clinics have also ceased to treat one-third of their 16,000 Medicare patients.

Pancreatic cancer patient Harold Rosen, 81, has been receiving chemotherapy at one of Vacirca’s cancer centers, but sequester cuts will soon change that.

“When I first came here, I was afraid to come because everyone’s dying. But everyone here is so pleasant. They smile, they laugh, they care about you. You would never know it’s a place of cancer,” Rosen said to NBC News. Rosen’s physician told him he must start receiving treatment in a hospital.

Vacirca said he is sad to turn away patients like Rosen, but he insists he must.”I have to be financially responsible to be here,” he said. “I owe it to my patients to not go out of business.”

Although Medicare is only facing a 2 percent reduction in funding- much less than other federal programs- oncologists say cancer patients are losing the most.

Seniors’ medications are mostly covered under the optional Medicare Part D. However, cancer drugs must be administered by physicians, and they are paid for by Medicare Part B. Part B covers doctor visits and is facing the sequester’s cuts.

According to Kliff, “The federal government typically pays community oncologists for the average sales price of a chemotherapy drug, plus 6 percent to cover the cost of storing and administering the medication.” But physicians cannot change drug prices, so the 2 percent cut will have to come out of the 6 percent cover charge- “akin to a double-digit pay cut” for clinics.

A recent survey of more than 300 oncology practices by the Community Oncology Alliance determined that 72 percent of them will change how they treat Medicare patients if the cuts continue.

The Alliance has pledged to “fight this unjust and devastating cut to cancer care” with an online petition.

A Milliman report shows that half of all U.S. cancer spending is associated with Medicare beneficiaries. Chemotherapy in hospital settings costs the federal government about $6,500 more than treatment in community clinics does. Some of those costs are then handed to patients, who pay another $650.

Will hospitals be able to absorb these patients? The same study shows almost 70 percent of Medicare patients receiving chemotherapy are treated in community clinics. Clinics in Connecticut, New York and South Carolina have already stopped treating patients.

What is the sequester?

In 2011, Congress passed a law stating that if no legislation was passed to reduce the federal deficit by $4 trillion, some $1 trillion in automatic budget cuts would take effect in 2013.

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As Americans live longer, organ donations suffer

As Americans are living longer than ever, many elderly would-be organ donors are unable to donate upon their death, according to analysis from executives of Gift of Hope, an organ donation organization in Illinois.

Gift of Hope

As Gift of Hope does not accept organs from those older than 85, with certain cancers, HIV or hepatitis B, many in need of multiple organs are struggling to get them. Although the number of living donors has remained steady over time, the number of donors actually able to donate is shrinking. Therefore, an average 65-year-old in need of a liver and kidney waits much longer for those organs.

“What we’re seeing is more people becoming sicker and getting less health care,” Eric Price, a donation specialist with Gift of Hope told LMM. “Because there is a static number of people donating, there are less organs coming from them.” Price also noted an increase in diabetes and cancer in would-be donors.

The biggest obstacle donation specialists face is finding the best time to request organs from grieving families. Specialists typically make this inquiry in the delicate moments before or after a potential donor’s death.

“There is no good time to ask this question,” Price said. “Families don’t want us coming to them in the hospital asking for their loved one’s organs.” But hospitals have an obligation to notify Gift of Hope of every pending death within a facility, or the institution risks losing Medicare reimbursements. If the individual on the verge of death meets the specifications of Gift of Hope, a donation specialist heads to the hospital immediately.

Sometimes, families are reluctant to donate because they hold out hope for a recovery, Price said. Poor doctor-family communication is another reason why more are not organ donors. “So many doctors do a horrible job of explaining death to families in general, but especially brain death,” Price explained. “I’ve been yelled at and even swung at once when speaking to a family about donating their loved one’s organs.”

A sense of urgency pervades organizations like Gift of Hope. There exists a small time period in which vital organs can be harvested, because they require oxygen and nutrients to survive. It is also difficult to find donors, as only two percent of deaths are eligible for donation. An eligible donor must have died a “brain death” within a hospital (like from a stroke) or the patient’s family has decided to withdraw life-saving support.

Deaths in hospice facilities or at home do not qualify, because organs cannot be harvested if not ventilated properly.

Meanwhile, the transplant waiting list keeps growing. A patient awaiting a kidney transplant in Illinois typically receives one after about five years. There are more than 5,000 people waiting for organs in Illinois. Nationally, that number is more than 100,000.

Gift of Hope executives acknowledge the emotional nature of their work and urge families to think of the positives of organ donation.

“After a family donates, we keep in touch with them,” said Karen Cameron, the Clinical Training Coordinator at Gift of Hope. They connect willing organ recipients and the donor’s family “to help show them the impact of their gift.”

More than five million people have signed up to be donors in Illinois, and more than 70 percent of those whom Gift of Hope approach agree to  donation.

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GSN’s David Goldhill: “American health care killed my father”

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GSN’s David Goldhill: “American health care killed my father”

Game Show Network President David Goldhill says it was the American health care system that killed his father, not the pneumonia for which he sought treatment at a New York City hospital. He addressed the need for health care overhaul at last weekend’s Association of Health Care Journalists conference in Boston.

Goldhill

Goldhill’s newly released book, Catastrophic Care: How American Health Care Killed My Father- and How We Can Fix It, outlines his helplessness in watching his father acquire a hospital-borne infection and subsequent five-week stay in the ICU. Goldhill argues his death, at 83, was entirely preventable and all too painful for both his father and family.

“If you’ve had a loved one die in the hospital, you’ve likely seen someone tortured to death,” Goldhill said to room filled with journalists. His argument is based in his belief that the health care industry fails to adopt cost-saving, life-saving ideas because the incentives in the business are “fundamentally broken.”

Americans, Goldhill argued, have learned to accept medical mistakes as inevitable, whereas in the restaurant industry, eateries can be shut down after one meal served tainted with something suspicious- often of dubious origin.

“In hospitals, we took the most personal, heterogeneous, important service and we have made it impossible- impossibly expensive, impossibly complex and completely lacking in accountability,” Goldhill said.

His father’s death was one of more than 200,000 each year due to medical error, and his gargantuan medical bill was covered by Medicare. One of Goldhill’s many sources of anger is how a failing product- the health care delivered to his father- could be compensated in full. He writes that high costs, over treatment, bad service and error are the inevitable consequences of an insurance-based system.

Americans typically have more coverage than they need at any one point, and Goldhill cited one of his 23-year-old full-time employees. If she marries, has two children, and her income grows annually at 3 percent, that woman will pour $1.8 million into the health care system- more than her family will likely ever use.

“It’s time to hold this industry accountable to standards of service, quality, consistency and value, and then it will start to change.”

Goldhill said the average healthy senior spends $5,500 each year on health care. “The amount of health care (seniors) are getting is genuinely frightening,” he said.

It is estimated that ten percent of the American population assumes 70 percent of the care, and Goldhill used this statistic to bolster his claim that “we define the whole system on the basis of the most extreme cases.”

How can the health care system change?

Goldhill argued that the Affordable Care Act will not fix the problem. National insurance does have a role, but for catastrophic events only. In other cases, individuals should use health care savings accounts to pay for other things, like routine exams or management of chronic conditions. Goldhill acknowledged such a change will take some time, likely two generations, and will only come about if prices come down.

Prices would drop, he said, if the industry would reorganize itself to serve consumer needs. This reorganization would happen if resources that currently pay for non-catastrophic events transfer to health savings accounts.

As an example, Goldhill cited the development of the personal computer. In its advent, the computer was one of the most expensive products for sale. It’s initial $18,000 cost translates today to roughly $200,000. “If someone had said to you back then that within a few decades, we would have one in every pocket, it would have been an argument for greater spending in mental health,” an amused Goldhill said.

But it happened. Why? “We created billionaires out of people that have figured out how to make them simple, accessible and cheap,” Goldhill answered.

The same, he said, could be true for health care.

“It’s time to hold this industry accountable to standards of service, quality, consistency and value, and then it will start to change.”

-Randi Belisomo

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Geriatrician shortage unlikely to be remedied

Image: DeviantArt via Creative Commons
Image: DeviantArt via Creative Commons

“Aging Americans are the elephant inside the demographic pyramid.”

There are too many old people in America and not enough geriatricians to care for them all, said leading elder care professionals at the Association of Health Care Journalists Conference in Boston, MA.

The rift between the growing elder population and the declining number of physicians trained in geriatrics will only grow larger in the coming years, said Sharon Levine, M.D., a professor in the Department of Medicine Geriatrics at Boston University School of Medicine.

“Aging Americans are the elephant inside the demographic pyramid,” said Levine.

With the population of those 85 and older increasing at four times the rate of other Americans, an estimated 30,000 geriatricians will be needed by the year 2030. Levine explained that this target can be hit only if 1,200 medical students enter geriatric medicine fellowship programs each year for the next two decades.

However, such entrance levels are far from likely. Only 75 medical school graduates entered geriatric fellowships in 2010, according the The American Geriatrics Society. That number was down from 1,120 in 2005.

Levine insists that dwindling interest in geriatrics is due, in large part, to increasing medical school debt and significantly less earning potential. In 2010, a geriatrician’s median salary was $183,523. That was almost six thousand dollars less than the average salary of a family physician, and close to $22,000 less than the average salary of a general internist. Geriatricians must train at least one year longer than their colleagues in primary care.

Currently, there are currently 3.8 geriatricians for every 10,000 older Americans. Elderly living in the Sun Belt and New England have the more geriatricians per capita in their regions than elderly patients in other parts of the country.

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An OP-ED for PBS: Inequalities in the health care system

Texas bill would clarify end-of-life treatments

-Randi Belisomo

An OP-ED for PBS: Inequalities in the health care system

Life Matters Media co-founder Mary F. Mulcahy, M.D., published her research about the racial and economic inequalities in the U.S. health care system for PBS. She continues to spread the message of advance care planning.

Mary F. Mulcahy
Mary F. Mulcahy

She writes:

“Racial disparities and inequities in American healthcare are evident in daily life, but regrettably they are also prominent in death. In these final days of Black History Month, it is imperative to reflect on the final days of all African-Americans and the choices they have within our health care system. These are the choices they aren’t taking, and the phenomenon serves as a means of further disenfranchisement from the medical community at large.

“The National Center for Health Statistics reports that African-Americans in home health care and nursing homes are half as likely as whites to have an advance directive, such as a living will or a do-not-resuscitate (DNR) order. This disparity leaves African-Americans at risk for unwanted medical procedures, unnecessary pain and family strife.”

Read the rest at PBS

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Texas bill would clarify end-of-life treatments

Source: Brown University, Joan Teno
Image: Brown University, Joan Teno

Current Texas law allows medical centers to stop treating terminally ill patients when such effort is deemed “futile.” Now, a Texas lawmaker is proposing a bill that would make it easier for family and patient surrogates to dispute decisions that terminate treatments for their loved ones.

The bill would revise the Texas Advanced Directives Act of 1999, which regulates how and when physicians allow patients to die. Currently, a medical center may discontinue treatments deemed “inappropriate” by the treating medical team only after ten days notice has been given to a patient’s family or decision-maker.

The proposed bill, sponsored by Republican State Senator Bob Deuell, would extend the time families who disagree with the medical center have to find a provider willing to continue treatments, from 10 days to two weeks.

It also adds language that clarifies “for whom life-sustaining treatment would be medically inappropriate and ineffective,” Dr. Arlo Weltge, who practices emergency medicine in Houston, told The Texas Tribune.

If a center’s decision goes before an ethics committee, current law provides 48 hours of notice before the meeting would be held. Deuell’s bill requires one week’s notice and would grant the family a patient liaison to guide them through the process, the Tribune reports.

If both the attending physician and the ethics committee conclude life-sustaining treatment is medically inappropriate, the patient may be moved to another facility willing to continue treatments. The patient would be liable for all costs incurred during transfer to the new center.

Supporters include the Texas Catholic Conference, the Texas Medical Association, the Texas Hospital Association, the Texas Alliance for Life and the Christian Life Commission. “We are pleased with Sen. Robert Deuell’s bill as a starting point for this reform. Our organizations look forward to working with Senator Deuell and the Texas Legislature during the 83rd Legislative Session to improve TADA,” a joint statement read.

In 2009, a similar bill passed the Senate but was halted in the House. This bill’s fate is still unclear.

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Image: Couple by George Hodan
Image: Couple by George Hodan

Modern medicine allows the terminally ill to survive longer than ever, but debate continues about how much should be spent on aggressive end of life care and if such care is actually best for patients. TEDMED facilitated a live discussion about some possible solutions to these challenges with industry experts this week, as part of its Great Challenges series.

In 2010, Medicare paid $55 billion on doctor and hospital bills during the last two months of patients’ lives- more than the budget for the Department of Homeland Security, according to CBS News. Some 20 to 30 percent of those medical expenses may have had no meaningful impact on the patients’ health, according to the analysis.

The discussion tied those problems to the need for better advance care planning and communication between doctor and patient. End of life concerns take an emotional toll on a patient’s family and friends, especially in the absence of advance care plans, such as a living will or POLST form.

Some families may insist on more aggressive care for the patient because of religious or societal expectations. Some doctors do not adequately communicate a patient’s condition to family, providing loved ones with the false sense that more treatment will work. This failed communication often results in increased spending.

Medical schools continue to improve training in how to listen to patients and mind the severity of illnesses, said Richard Payne, M.D., professor of medicine and divinity at Duke University. “Generally, there is much more emphasis now on teaching doctors to listen empathically to patients and their wishes,” he said.

Although it may be difficult and uncomfortable, it is important to speak with loved ones about death and dying ahead of time, said Bruce Jennings, director of bioethics at the Center for Humans and Nature. “Advance planning and treatment planning are very important aspects of ensuring that the kind of care you receive at the end of life will be beneficial for you, and will respect your wishes and dignity,” Jennings said.

Debate about end of life care will become increasingly common. In 2000, there were more than 35 million Americans 65 and older. By 2030, there will be 72 million.

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Psychological responses to end of life

Nurses’ positive attitudes towards death and dying can alleviate the suffering of some terminally ill patients, according to new findings from Spanish researchers published in the International Journal of Nursing Studies.

Lead researcher Rafael Montoya-Juarez, from the University of Granada, and others sought to identify the psychological responses the terminally ill put in place to deal with the demands the end of life brings. The study is intended to be “a foundation for future nursing interventions.”

Researchers questioned 24 patients from various hospitals across Granada using a phenomologic approach. “Phenomenology is the appropriate theoretical approach to the study of suffering,” the researchers explain. “Because we assume a model of suffering based on the response to threats, we have transcended the purely descriptive approach by interpreting the data in light of this model.”

The participants’ answers to these questions allowed the researchers to identify a main category titled, “To realize that life is short.” As coming to terms with life’s finite nature is a main source of psychological discomfort for patients, it is also a starting point for developing psychological responses to reduce suffering.

Three categories emerged that showed different ways participants came to terms with death: “Re-Evaluation of life,” “Opportunity for growth” and “Resignation/Acceptance.”

Upon re-evaluating their lives, some patients became hopeful and reassured in feeling they met life’s major goals. “I have already done, as they say, the thing in life. I got married, I raised a child, I planted many trees in the field and I have done harm to no one and I am thus waiting for whatever God wants,” one participant said.

Others reported feeling more frustrated. ”This is one of the most saddening things, when you truly realize that life has an end, and you think, I did not do this or the other,” another participant told researchers.

Still, the dying process provided some participants with an opportunity for growth, the conviction that a terminal diagnosis helps determine one’s place in life. Those with this mindset tended to appreciate the simpler things in life. ”The illness has caused me to see life from a totally different perspective, to enjoy the small things and the big things, and to undervalue others,” another said.

Others said they felt  relieved that  life was coming to an end, and they had a sense of acceptance. “One has to accept and consider it as good because there is nothing that can be done about it,” one participant said. “You have to accept everything.”

Gender seemed to play a role in how an individual responded to a terminal diagnosis and death. Out of the fifteen men and nine women studied, men were more concerned about the loss of their job, social relationships and loss of physical functions. Women spoke more about their homes and daily routines, especially caring for their children. Women were also more likely to bring religion into their struggle, as if it were part of God’s will.

Nurses can alleviate the emotional impact of terminal illnesses on their patients by encouraging these psychological responses, the study concludes. Montoya-Juarez recommended that nurses provide realistic and achievable short-term goals for their patients, facilitate communication with family and enhance the feeling of satisfaction with life.

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