Tagged: chemotherapy

Hospice enrollment policies contribute to underuse of care

Hospice enrollment policies contribute to the underuse of hospice care in the U.S., according to new findings published in the journal Health Affairs. Findings from the first national survey on hospice enrollment policies found 78 percent had at least one policy restricting care access for high-cost patients.

Although almost all Americans live within close proximity to a hospice, more than half of patients eligible for the care die without it. There are more than 3,500 hospice providers in the U.S.

Some 600 hospices were studied, and according to researchers, “patients with potentially high-cost medical care needs, such as chemotherapy or total parenteral nutrition,” had a greater likelihood of facing the restrictions. Limited enrollment policies were identified in both for-profit and nonprofit hospices. These restrictive policies include not receiving chemotherapy, total parenteral nutrition, blood transfusions, an intrathecal catheter, radiation therapy, tube feedings or requiring a primary caregiver at home.

“It represents a barrier to people who want hospice care but can’t receive it,” said lead author Melissa Aldridge Carlson, a palliative care researcher at the Mount Sinai School of Medicine.

The aim of hospice care is to manage the pain and symptoms of the terminally ill so that their last days are spent with dignity. The care is not intended to treat the disease.  Hospice is most often used when curative treatment is no longer effective, and a terminal patient is expected to live about six months or less. Medicare states that to elect the Medicare hospice benefit, an individual “waives the right to receive all other Medicare covered services for the terminal illness and related conditions.”

Hospices may restrict access because of current Medicare reimbursements, which account for more than 80 percent of hospice revenue. The reimbursements do not cover treatments related to a patient’s terminal illness, so a hospice must pay for it. As Carlson points out, the average per diem reimbursement is only $140 per day.

The researchers explain, “many patients with terminal illnesses can benefit from using oral chemotherapy for palliative rather than curative purposes; radiation; or blood transfusions for treatment- or disease-related low blood cell counts.” Any one of these treatments can cost more than $10,000 a month.

Open access policies allow enrollment of those who are not yet eligible for the Medicare hospice benefit, anticipating that they will remain with the hospice when they do become eligible. Patients receive the medical comfort and social support available through hospice while simultaneously retaining access to medical treatments for their disease.  Such patients may be covered by private insurance plans or pay for the care out of pocket.  However, initial reports indicate that the cost of caring for patients enrolled through open access policies is generally absorbed by the hospice provider.

The authors conclude that increasing the hospice per diem rate for patients who require complex palliative treatments and removing the Medicare hospice benefit limitation on concurrent care may enable more hospices to expand their enrollment to patients who need and want it.  Providing hospice services in a cost effective manner for those whose treatment plans include concurrent life-extending and palliative care is the subject of the a pilot project funded by section 3131 of the Affordable Care Act, although results for this pilot project are years from completion.

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Life Matters Media featured in the Atlantic

Life Matters Media co-founder Mary F. Mulcahy, M.D., has shared her experiences treating the terminally ill for a new feature in the Atlantic.

Mary F. Mulcahy
Mary F. Mulcahy

When fighting cancer isn’t worth it

The war on cancer is a civil war. It is a battle of two armies, cancer and therapy, fighting it out within a common space. It is an unfair fight.

A recent article in the Washington Post describes a controversial surgery devised by a pioneering and big-thinking surgeon, Paul Sugarbaker. This surgical procedure, known as cytoreduction and heated intraperitoneal chemotherapy (HIPEC), removes metastatic cancer before bathing the abdominal cavity in heated chemotherapy. There are many who celebrate it as life-saving, some who loathe it as toxic, and others who debate its merits and shortcomings endlessly.

Read the rest at the Atlantic.

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Occupational stress: Doctors may suffer when unable to save lives

Physicians who treat the terminally ill may suffer from emotional stress when unable to save patients’ lives. Burnout and compassion fatigue are two serious forms of occupational stress physicians may suffer, according to research by Michael Kearney, M.D.

Kearney, a palliative care physician at Santa Barbara Cottage Hospital in California, describes burnout as “the end stage of stresses between the individual and the work environment.” Compassion fatigue is “secondary post-traumatic stress disorder, or vicarious traumatization — trauma suffered when someone close to you is suffering.”

Health care journalist Jane Brody addresses the stress and anxiety oncologists struggle with in a new article for The New York Times. Brody writes, “A doctor with compassion fatigue may avoid thoughts and feelings associated with a patient’s misery, become irritable and easily angered, and face physical and emotional distress when reminded of work with the dying.” Compassion fatigue may lead to burnout.

Up to 60 percent of practicing physicians report symptoms of burnout.

According to Brody: “Patients and families may not realize it, but doctors who care for people with incurable illness, and especially the terminally ill, often suffer with their patients. Unable to cope with their own feelings of frustration, failure and helplessness, doctors may react with anger, abruptness and avoidance.”

Physician suicide linked to occupational stress

According to Crystal Phend, senior staff writer for MedPage Today, ”Suicide among physicians appears to follow a different profile than in the general population, with a greater role played by job stress and mental health problems.”

Phend cites a study by Katherine J. Gold, M.D., of the University of Michigan in Ann Arbor, who found that problems with work were three times more likely to have contributed to a physician’s suicide than a nonphysician’s. Mental illness was also 34 percent more common before a suicide among physicians.

Up to 60 percent of practicing physicians report symptoms of burnout

“The results of this study paint a picture of the typical physician suicide victim that is substantially different from that of the nonphysician suicide victim in several important ways,” Gold wrote for General Hospital Psychiatry. ”Inadequate treatment and increased problems related to job stress may be potentially modifiable risk factors to reduce suicidal death among physicians.”

Although physicians have more access to health care, they may be reluctant to seek help. ”I think stigma about mental health is a huge part of the story. There is a belief that physicians should be able to avoid depression or just ‘get over it’ by themselves,” Gold wrote.

More than 200 of the 31,636 suicide victims reported in the National Violent Death Reporting System from 2003 to 2008 were physicians.

Meditation may help physicians

A 2008 study published by the Journal of Palliative Medicine, in which researchers studied 18 oncologists, found that physicians who viewed their work with patients as both biomedical and psychosocial found end of life more satisfying than those with a more biomedical perspective.

“Physicians, who viewed their physician role as encompassing both biomedical and psychosocial aspects of care, reported a clear method of communication about end of life care, and an ability to positively influence patient and family coping with and acceptance of the dying process,” the researchers concluded.

“In contrast, participants who described primarily a biomedical role reported a more distant relationship with the patient, a sense of failure at not being able to alter the course of the disease, and an absence of collegial support.”

Kearney recommends “mindfulness meditation,” a Buddhist-influenced practice for physicians suffering from stress. “The doctor is able to recognize he’s being stressed, and it prevents him from invoking the survival defense mechanisms of fight (‘Let’s do another course of chemotherapy’), flight (‘There’s nothing more I can do for you — I’ll go get the chaplain’) and freeze (the doctor goes blank and does nothing).” He claims that even 8-10 minutes a day of “mindfulness meditation” can help.

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How much is three months of life worth?

Some oncologists believe that the near-constant developement of new cancer treatments does more for the pharmaceutical industry than for patient recovery. Many popular drugs that aim to fight cancer have had limited success, partly because many of the disease’s genetic traits remain unpredictable. Laura Beil’s latest feature in Newsweek focuses on the cost-benefit dilemma. Is it justifiable to tack on high costs to an already burdened health care system for a few more months of life?

Avastin, Perjeta and proton radiation all had positive hype upon approval and have been used by thousands of Americans cancer patients. But, Avastin’s cost is extraordinary.

Beil writes: “Consider the popularity of Avastin, a targeted drug approved for metastatic colon cancer in 2004. A recent study found that almost 70 percent of patients on chemotherapy were receiving Avastin within a year of its release. In clinical trials, the drug increased survival by about five months. The cost? About $10,000 a month.”

Perjeta, a first-line treatment for metastatic breast cancer, was also highly anticipated. Dr. Lowell Schnipper, chief of oncology at Beth Israel Deaconess Medical Center in Boston, says: “Perjeta gives the average woman only about six months more of calm before her disease starts to stir again. Given the limited benefit, the price was startling. For most women, a full course of the drug combination will cost $188,000.”

In 2001, there were three centers offering proton treatment in the U.S. There are now ten, and six more planned. Mayo Clinic has already began planning for a center in Arizona, while 21st Century Oncology has begun plans for a New York facility, both slated for 2016. Three quarters of patients using these facilities are men with prostate cancer who are covered by Medicare.

Pharmaceutical companies have two main advantages when it comes to health care costs. Many doctors and patients are willing to try new and expensive treatments, even with limited hope of therapeutic benefit.

They also justify costs of drugs. “Pharmaceutical companies say it’s payment for scientific creativity, that high prices are necessary to recover the expense of developing and manufacturing their products and to encourage more research,” writes Beil.

A 2004 study published in the Journal of Clinical Oncology found that “the drug companies are not pricing their drugs to recuperate losses associated with research and development, marketing, and operating prices, but rather [the average wholesale price] depends on what the market itself can bear.”

Reuters also reports on the growing financial costs of cancer treatments. “U.S. spending on oncology drugs and their administration is expected to rise more than 20 percent annually for the next few years, reaching $173 billion by 2020, according to Express Scripts, which manages prescription drug benefits for employers and other clients.

“As scientists unravel the biological underpinnings of cancer cells, new targeted therapies are being developed, but the process is expensive. Avastin, a drug designed to cut off a tumor’s blood supply, can cost $8,000 a month, while a course of treatment with Provenge, a therapeutic vaccine for prostate cancer, is priced at $93,000.”

Learn more about the cost of cancer drugs at NPR.

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In America, death is taboo

Are new technologies and medical treatment making Americans less comfortable with death? The Milwaukee Journal Sentinel has published a feature by practicing cardiologist and former hospice director Bruce Wilson. Wilson recounts an experience he had counseling a friend whose mother declined aggressive cancer treatments for her terminal diagnosis. Wilson’s succinct commentary focuses on the taboo nature of death in America and how the culture is changing that.

Wilson writes about when his friend Jack came to him for support: “Jack’s mother had seen her doctor who had ordered a routine CT scan. Unfortunately, there was evidence of the cancer having spread to her liver. She had explored the options with a number of physicians and had decided that she was not interested in chemotherapy or more surgery to treat her spreading, and therefore terminal, disease.”

Like many in his position, Jack was upset that his mother would no longer be accepting of treatment, even though she could possibly recover. This uncomfortable experience would lead Wilson to explain America’s unnerving relationship with death.

Accepting mortality has become harder because death is now so uncommon. According to Wilson: “Death has become a taboo subject, but it hasn’t always been so. It seems to be feared mostly because as a society we have become so unfamiliar with death. Medical science has evolved very rapidly, and over the past 50 years we have become so good at treating illnesses that we somehow have come to view death as an option. Before heart surgery and angioplasty and antibiotics and chemotherapy, people often died when they got sick.”

Since death has become a taboo subject, hospice care, assisted suicide, or “hastened death” as Wilson calls it, are viewed as giving up or immoral. Hospice care is becoming increasingly popular for its cost and comfort focus.

“The number of hospice patients on Medicare doubled to 1.1 million between 1998 and 2008, according to the federal Centers for Medicare & Medicaid Services. Another estimate of hospice patients this year, from the National Hospice & Palliative Care Organization, put the number at 1.6 million,” writes Jim Doyle for the St. Louis Post Dispatch.

There are a growing number of states allowing assisted suicide. Wilson writes: “Many people in the U.S. are now making choices at the end of life that are viewed by some as radical. Physician-assisted suicide is legal in Oregon, Montana and Washington and is on the legislative docket in one form or another in a number of other states. Massachusetts will vote on this in November.” Wilson believes assisted suicide is more about the quality of one’s last days and not the number of one’s last days.

Learn more about the pending Mass. law here.