Tagged: physician

Vermont votes to allow “Death with Dignity”

The Vermont House approved a measure allowing physicians the ability to prescribe life-ending medications to some terminally ill patients seeking to end their lives. Vermont is set to become the fourth state allowing the legislation known as ”Death with Dignity,” following Oregon, Washington and Montana.

Photo by Jeb Wallace-Brodeur

The Patient Choice and Control at End of Life Act awaits approval from Gov. Peter Shumlin, a Democrat and supporter of the bill.

“By a 75-65 roll call vote, the House approved a bill largely that copies a law passed by Oregon voters in 1997 for three years and then shifts to a system with less government monitoring,” The Associated Press reports.

This marks the first time this type of legislation has been moved to passage by a legislature. With safeguards similar to the Oregon bill, patients seeking the prescription barbiturates must first state their intentions three times- once in writing. A second opinion from a physician indicating a patient has less than six months to live and proof of sanity, are mandatory. Patients must wait 48 hours before filling the prescriptions.

“It’s an important step for terminally ill Vermont patients,” Dick Walters, president of Patient Choices-Vermont, said after the vote. “It’s a big step forward for the region and for the country as a whole,” the AP reports.

Come 2016, changes advocated by some of the state senators seeking less government involvement during the process will go into effect, including less monitoring from physicians.

“It’s huge,” said lobbyist Michael Sirotkin, who for years has been involved with the issue in Vermont. “I think it’s going to have a major effect on other states’ willingness to vote on this,” he told USA Today.

But not all lawmakers approved of the bill’s passage. ”There can never be a dignified death using a handful of pills or a lethal cocktail,” said Rep. Carolyn Branagan, a Republican from Georgia, VT.

Other opponents were concerned about the radical changes the bill underwent while in the Senate. ”We are passing a bill that has not been vetted,” said Rep. Paul Poirier, an Independent from Barre. “Do we want to pass a bill … just accepting 100 percent what the Senate did overnight?”

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Montana HB505: Outlawing assisted suicide

Flickr
Image: Flickr, Alex Proimos

Montana lawmakers are considering a controversial bill to outlaw physician-assisted suicide, a decision that opponents say would punish doctors for honoring their dying patients’ wishes. If the bill passes, physicians who provide life-ending drugs could face 10 years in prison and a $50,000 fine.

Introduced by Rep. Krayton Kerns, a Republican, HB505 seeks to clarify “the offense of assisting in suicide,” after a 2009 Montana Supreme Court decision left many confused about the issue.

Known as the Baxter Decision, the court ruled physicians that prescribe life-ending drugs are safe from prosecution, because “nothing in Montana Supreme Court precedent or Montana statutes [indicates] that physician aid in dying is against public policy.” However, the decision did not address whether assisted suicide is a right guaranteed under the state Constitution.

Kerns insists the ruling needs clarification. ”The Baxter Decision did not establish legal assisted suicide in Montana, and this has remained a gray area,” Kerns told the Great Falls Tribune. ”This bill would be a legislative declaration saying it is illegal based on constitution principles.”

According to the bill, “A person who purposely aids or solicits another person to commit suicide, including physician-assisted suicide, commits the offense of aiding or soliciting suicide.” Consent of the patient would not be a defense. However, withholding life-sustaining treatments from terminally ill patients would remain legal.

Critics argue the bill would curtail patients’ end of life choices. Opponent Bonnie Warne of Billings told the Billings Gazette that doctors who provide life-ending drugs to their patients would be unfairly attacked. “Death is inevitable and private. We do not need the state interfering with aid in dying,” she said.

Dan Lourie, from Bozeman, wrote a letter to the Montana Standard arguing that if the bill passes, he would be forced to forfeit his doctor-patient privacy. “My position is that my end-of life choices should be between me and my doctor, and the Montana Supreme Court agrees with me,” he wrote. “It should be my right, and certainly will be my desire, to discuss all of my choices with my doctor — treatment options, my choice to refuse treatment, pursuit of comfort care and assistance in dying.”

Compassion and Choices, a non-profit that serves to expand end of life options, maintains the bill would “roll-back” end of life legislation.

“HB505 goes beyond just prohibiting aid in dying by putting a physician at risk of prosecution for answering a patient’s questions about any of a variety of death hastening options, such as directing deactivation of a cardiac device, directing withdrawal of a ventilator or feeding tube, or provision of palliative sedation; and a spouse, child or friend could be prosecuted for driving the patient to the doctor’s office for the discussion,” a statement posted on their Web site read.

If the bill were to pass, palliative care would still be allowed for terminally ill patients, because palliative care serves to manage pain and ease suffering.

Hearings about the bill began this week.

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Spirituality at end of life: Practitioners remain hesitant

Spirituality

Physicians and nurses at Boston medical centers cited a lack of training as the main reason why they rarely provided spiritual care for their terminally ill cancer patients, even though most patients considered it important to their end of life care.

A new study published in the Journal of Clinical Oncology reports that out of the 204 physicians from four medical centers who participated in the three year study, just 24 percent reported providing spiritual care. Among the 118 nurses, only 31 percent reported providing care.

“I was quite surprised that it was really just lack of training that dominated the reasons why,” senior author Dr. Tracy Balboni, an oncologist at the Dana-Farber Cancer Institute in Boston and researcher of spirituality, told Reuters Health.

Spiritual care may range from prayer with a physician or nurse to recommendations for a hospital chaplain.

Spiritual care “is considered by patients to be an important aspect of end of life care and is also associated with key patient outcomes, including patient quality of life, satisfaction with hospital care, increased hospice use, decreased aggressive medical interventions, and medical costs,” Balboni said.

Even though current palliative care guidelines encourage medical practitioners to mind religious and spiritual needs that arise during a patient’s end of life care, most medical practitioners remain silent. Ninety-four percent of patients with advanced cancer had never received any form of spiritual care from physicians.

Stanford School of Medicine
Stanford School of Medicine

Spiritual care may become more common in the future, however. “There was a time when nurses and physicians may have said, ‘That’s not my job,’ but I think the tides are changing,” said palliative care researcher Betty Ferrell of City of Hope, a cancer research center in Duarte, California.

“I think we are realizing we can no longer ignore this aspect of care,” Ferrell told Reuters. She’s a professor of nursing who was not involved in the new study.

Study researchers suggest more spiritual care training for physicians and nurses. The study found only 13 percent of doctors and nurses reported having such training. However, those who received training were almost 11 times more likely to provide spiritual care to their patients than those who had not.

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How POLST forms clarify wishes: Three scenarios

The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve end of life care in Illinois, is on its way to implementation. Health care professionals met at Rush University Medical Center this week to discuss the form’s development and strategies for raising public awareness.

Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center, provided the audience with hypothetical scenarios the POLST program form could remedy.

POLST program forms are more detailed than conventional living wills or other advance directives. They allow people to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for people who are likely in their last year of life.  They can follow patients across in-state care settings and direct doctors to provide or withhold life-sustaining treatment in emergency situations.

The forms aim to more quickly direct doctors to a person’s wishes and eliminate confusion about what patients would want in the case that they are medically incapacitated and unable to communicate their wishes.  The forms provide instructions in the case of a cardiopulmonary arrest (the person has no pulse and is not breathing), the degree of medical intervention they would want in a pre-arrest situation (the person has a pulse and/or is breathing), and whether or not they would want artificial nutrition if their medical illness prevented them from taking in adequate oral nutrition.

How a POLST form could help

A 67-year-old man is sent to the emergency room with chest pain and shortness of breath. He is also confused. The cardiologist says that a cardiac catheterization with angiogram and a stent are needed. The nurse tells the physician that there is a DNR order on his chart. Should the physician send the patient for an angiogram? It’s not clear. 

If that patient had a POLST form that indicates DNR in case of full cardiac arrest but an order for full treatment in a pre-arrest emergency, the physician would immediately know what to do. The patient would be sent for the angiogram.

An 85-year-old man is admitted to the emergency room with severe pneumonia. He’s hypoxic, confused and refusing the ventilator. There is a DNR order on the charts. The physician feels that DNR doesn’t apply to this potentially reversible condition but the nurses disagree. He receives full resuscitation. 

If that same patient had a POLST form indicating no CPR in the case of arrest and a preference for comfort care, the physician and nurses would have clear instructions.  He would not have undergone full resuscitation, but would have been maintained in comfort with noninvasive maneuvers.  .

A 59-year-old woman who is being treated for breast cancer is admitted to the emergency room for sepsis. She is transferred to intensive care and receives oxygen and maximum vasopressors. She has a DNR order on the charts. The staff are concerned that they are violating her wishes.

If she had a POLST form indicating no CPR in the case of arrest but limited interventions in addition to comfort measures, the staff may feel more comfortable treating her as they are doing and spend less time deliberating.

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POLST Illinois moves forward

The Physician Orders for Life-Sustaining Treatment (POLST) program, designed to improve the quality of end of life care, is on its way to Illinois. Health care professionals met at Rush University Medical Center Thursday to discuss the form’s development and strategies for raising public awareness.

Sample POLST

The Chicago End-of-Life Care Coalition sponsored the discussion led by Julie Goldstein, M.D., a clinical ethicist and palliative care physician at Advocate Illinois Masonic Medical Center.

POLST program forms are more detailed than conventional living wills or other advance directives. They allow patients to indicate preferences regarding resuscitation, intubation, intravenous antibiotics and feeding tubes. Such forms are intended for patients in their last year of life, and they can follow patients across in-state care settings and direct doctors to provide or withhold life saving treatment in emergency situations.

For instance, an individual may choose to decline resuscitation efforts, but of for artificial nutrition. An individual may choose artificial nutrition with set limits or permanent placement.

Goldstein answering audience questions

“POLST improves on the existing uniform DNR form,” said Goldstein. “POLSTs are medical orders and have to be followed by all medical care providers.” To be valid, a POLST form must be signed by an attending physician.

Loretta Downs, president of the CECC, told LMM that POLST is essentially about enhancing personal liberty at end of life. “For Illinois, accepting the POLST form is a statement encouraging people to take advantage of their liberty regarding end of life decisions. It empowers the individual to make a clear statement about whether or not he or she wants end of life care and what level of treatments.”

The POLST form will be available in early 2013, a version of the IDPH DNR Uniform Advance Directive. Goldstein said it will be most similar to the California POLST. The final form awaits approval from state health officials and it may be “ultra pink.”

Many in attendance left hopeful that the form would help their patients. Kriston Kurelic, a social worker at Passages Hospice, says she is excited about the form’s implementation. “I’m very interested in the changes that will happen,” Kurelic said. “It will be very beneficial to long-term care. It will be beneficial to patients and families.”

Christine Nelson, director of nursing at Manor Care, agrees. “I think anything that helps us assess what people’s wishes are more clearly is helpful,” she said. “The only barrier I see is time being taken to explain the form to patients.”

The task of educating patients will likely fall on individual health care providers. Because it is a physician order, it is intended to be accompanied by a meaningful doctor-patient dialogue. Carol Blendowski, a Rainbow Hospice nurse practitioner, says time is what is required to have such conversations, but thinks patients will ultimately find the POLST easy to navigate. “I can see clearly now,” she said. “This form is user friendly.”

POLST was developed in Oregon in the 1990s, and now 15 states have POLST programs. Twenty-eight states are considering the use of POLST forms.

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What is palliative, hospice care?

POLSTs work, says Respecting Choices’ Bernard Hammes

What is palliative, hospice care?

Despite its growing popularity in hospitals, most Americans remain unaware of the comfort and benefits palliative care can provide some terminally ill patients.

“There is a clear need to inform consumers about palliative care and provide consumers with a definition of palliative care,” researchers commissioned by the Center to Advance Palliative Care advise. According to Public Opinion Research on Palliative Care, seventy percent of the general population doesn’t know anything about palliative care, and 14 percent were “somewhat knowledgeable.”

The researchers also found that it is difficult to inform physicians about palliative care, because they often wrongly equate it with hospice or end of life care.

Public Opinion Strategies

Palliative care becoming more popular

Palliative care is treatment that enhances comfort and improves the quality of life for patients in life’s last phase. No therapy is excluded from consideration, according to the National Hospice and Palliative Care Organization (NHPCO).

Palliative care is becoming increasingly widespread. There are more than 1,600 hospitals that have palliative care programs in the U.S., according to Dr. Diane Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine. Some 85 percent of large hospitals have a palliative care team. Sixty-seven percent of small hospitals have programs.

Dr. William H. Frist, a heart transplant surgeon and former U.S. Senate Majority Leader, recommends palliative care. ”[A] brand new field in medicine is making chronic, agonizing, and even terminal illnesses much more manageable… palliative care has emerged as the best solution for those facing serious, painful diseases, and introduces the very real possibility… that we can now live with these diseases for a long time,” he wrote recently for The Week.

Public Opinion Strategies

Palliative care also costs much less than aggressive end of life regimens. Patients who receive palliative care services cost hospitals between $1,700 and $5,000 less per admission, according to findings published in the Archives of Internal Medicine.

Hospice care remains overlooked

Hospice care is different from palliative care; its aim is to manage symptoms so that a person’s last days are spent with dignity and quality. The care is not intended to treat the disease but the person, according to the American Cancer Society.

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.

“Many people believe that hospice is only for people who have cancer. This may be due to the fact that many of the patients cared for in the early days of hospice were cancer patients,” Becky Hillier, public relations director for Rocky Mountain Hospice, wrote for the Montana Standard. Less than 25 percent of hospice patients admitted to the hospice are cancer patients.

The NHPCO reports that 36 percent of hospice patients die or are discharged within seven days of treatment. Many terminally ill suffer more than they need to because they wait to enroll in a hospice program.

“We continue to see more dying Americans opting for hospice care at the end of their lives, yet far too many receive care for a week or less,” said the NCPCO’s J. Donald Schumacher. “We need to reach patients earlier in the course of their illness to ensure they receive the full benefits that hospice and palliative care can offer.”

One reason the terminally ill wait for hospice, he said, is due to the misconception that hospice means giving up.

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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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End of life care varies across top hospitals

The nation’s top 23 academic medical centers differ significantly in intensity of care provided to patients near the end of life, according to findings from the Dartmouth Atlas Project. The report, ”What Kind of Physician Will You Be,” is intended to help fourth-year medical students find the best residency to complete their training.

The authors suggest that when terminally ill patients receive unnecessarily aggressive and expensive care, quality of life diminishes. “Hospitals providing a higher intensity of care did not generally score higher on measures of patient experience, patient safety, or processes of care.”

The report’s premise is that physicians who complete their residencies at hospitals with more effective end of life care will be in a better position to not only serve patients, but to reform health care as well.

“Your choice in a residency program will shape your care for patients for years to come and can also present opportunities to lead improvements in health care,” the authors, including Anita Arora, M.D., Geisel School of Medicine at Dartmouth, write in their report.

The culture and environment of medical centers, described as the “hidden training curriculum,” impacts how doctors interact with the terminally ill, but such culture isn’t widely reported to prospective students. This report aims to remedy that.

“To compare the overall treatment of chronically ill patients, the report calculated a hospital care intensity index that combined the average number of days these patients spent in the hospital in the last two years of their life and the average number of physician visits in the same period,” Duke’s Chronicle reports.

Hospice care enrollment rates during the last six months of life was one area in which hospitals differed widely. The University of Michigan Medical Center had 59.1 percent of patients enrolled in hospice, while Mount Sinai Medical Center only had 23.1 percent.

The report also found that NYU’s Langone Medical Center had 66.6 percent of patients in their last six months of life seeing 10 or more doctors, while St. Mary’s Hospital / Mayo Clinic had only 52.4 percent seeing the same amount.

“Learning how to use health care resources wisely, provide high-quality care, and incorporate patient preferences into a care plan is just as important as learning to work up a patient,” said Alicia True, a co-author of the report and medical student at the Geisel School of Medicine at Dartmouth.

Learn more from the Life Matters Media Newswire.

POLSTs work, says Respecting Choices’ Bernard Hammes

Massachusetts ballot initiatives results

NM court to define assisted suicide

The debate involving assisted suicide continues in New Mexico, as the Second Judicial District Court of New Mexico and two doctors struggle to define what the term really means. The Denver Post is reporting that a N.M. district court will define what “assisted suicide” is. Currently, the state statute prohibits assisted suicide, but debate persists if that statute applies in late stages of terminal illness as a treatment option.

According to the Post’s Diane Carman: “Two oncologists from the University of New Mexico Health Science Center and a patient with advanced cancer are the plaintiffs in a lawsuit filed in New Mexico District Court designed to clarify the legal definition of assisting suicide. That decision, likely to come in the next year, could send reverberations through the medical establishment in the Rocky Mountain West and across the country.”

Katherine Tucker, the legal affairs director of Compassion & Choices, a non-profit which aims to expand end of life options, is also one of the attorneys representing the plaintiffs in the case.

The Los Angeles Times’ Steve Lopez reports, ”Tucker said the case in question involves a woman with advanced uterine cancer who has said she would like to have, as one option, the right to avoid prolonged suffering by obtaining doctor-prescribed medication she could ingest to bring about a peaceful death if she finds her dying process unbearable.”

Plaintiffs in Morris v. New Mexico contend that the dying process was not considered part of the statute, as opposed to assisting in suicide in which an individual would otherwise live. “Morris v. New Mexico is modeled on Baxter v. Montana, which was decided by the Montana Supreme Court in 2009. In a 5-to-2 ruling, the Montana court said that physician aid in dying was protected under the law providing for living wills,” writes Carman.

As of now, the statute remains vague. According to Justia: Assisting suicide consists of deliberately aiding another in the taking of his own life. Whoever commits assisting suicide is guilty of a fourth degree felony,” is the current statute in N.M.

Some choose assisted suicide

According to a recent feature in The New York Times: “Dr. Richard Wesley has amyotrophic lateral sclerosis, the incurable disease that lays waste to muscles while leaving the mind intact. He lives with the knowledge that an untimely death is chasing him down, but takes solace in knowing that he can decide exactly when, where and how he will die.” Dr. Richards is based in Washington, which has the Death With Dignity Act.

Katie Hafner’s feature probes the issue of “Right to Die.” She notes critics of the law’s morality, some of whom feel the poor will be unjustly persuaded to die early for financial reasons. Ironically, Hafner notes: “Dr. Wesley is emblematic of those who have taken advantage of the law. They are overwhelmingly white, well educated and financially comfortable.”

The law is similar to what Massachusetts will vote on this fall. According to Hafner: “Two physicians must confirm that a patient has six months or less to live. And the request for the drugs must be made twice, 15 days apart, before they are handed out. They must be self-administered, which creates a special challenge for people with A.L.S.”

Some doctors, such as former president of the Massachusetts Medical Society, Dr. Barbara Rockett, oppose assisted death. “We as physicians must avoid the so-called slippery slope of attempting to save money by doing less for our patients rather than rendering the proper care to them. To substitute physician-assisted suicide for care represents an abandonment of the patient by the physician,” she wrote for Boston.

There is support for the Massachusetts law. Hafner quotes Stephen Crawford of Dignity 2012, “Support isn’t just from progressive Democrats, but conservatives, too.”According to Crawford: “It’s even a libertarian issue. The thinking is the government or my doctor won’t control my final days.”