Intro to Hospice

Background

Hospice care is a matter of staying in touch with your patient. As part of a team, you attend to an individual's comfort both physical and emotional, even after most of the diagnostic and curative work has been completed.

What is the purpose of my hospice rotation?

... This month can be a starting point to talk about specific clinical issues such as pain control, managing other symptoms (nausea, diarrhea, anxiety, dyspnea), respecting autonomy, and talking with individuals about difficult issues of mortality. Getting some practical guidance in these areas can help you not only with hospice care, but also with your care in any setting where you try to understand individuals and improve comfort.

... The purpose of your rotation is for you to experience, first hand, just what hospice is. Walking with a hospice nurse or physician as they care for individuals, you experience hospice. You see techniques of caring. You learn how others contribute expertise and services to form a team of caring providers. This can help you later when you discuss hospice with your own patients who face irreversible illness.

Where do I go and when?

... During your Ambulatory Care Rotation you will spend a half-day each week at Hospice of Cincinnati, in Blue Ash. Each Tuesday afternoon Pam McCabe RN or Linda Ruter RN will meet you in Blue Ash. Emphasis will be on visiting patients at home, as well as with the in-patient unit. Dr. Rebecca Bechhold, Hospice Director, will hold teaching sessions with you. (Discuss the division of your time with Pam.)

... We are also developing some time during the month when you will meet back at Good Sam with Dr. Koselka, Dr. Gandola or other physicians to discuss case histories, review relevant papers, visit our in-patient pharmacy's handling of pain medications, or share stories about patient care experiences.

Where can I read more about palliative care?

... Included here are some helpful handouts and suggested readings. Resources

Core Textbooks

Derek Doyle's Oxford Textbook of Palliative Care Medicine.1 is a storehouse on management of pain and other symptoms, as well as reviews of emotional and spiritual aspects of care.

More digestible is another book, MacDonald's Case-Based Manual.2 (This and the Oxford Textbook can be found in Good Samaritan's library.) Another suggestion is the pocket-guide format of Caroline's guide to symptom care.3

Reading Beyond Medicine--Learning About Life

A poem4 by Auden is attached. Learn what happens to Miss Gee and her physician.

To understand who we are, art and literature stand ready to help. 5-10 Read. Talk with people. Listen to your patients. Examine your own life. Your medical education & residency experience has shaped part of you.11-14 Your self-awareness is reflected in how you listen and talk with your patients.

Relieving Pain, Terminal Delerium, and Dyspnea

Many issues are covered in good reviews: Assessing an individual's pain, using proper dose intervals, converting from intravenous to oral, overcoming misconceptions of addiction which limit adequate prescribing to relieve pain, dealing with side effects of opiates (constipation, confusion, respiratory depression. Keep your eyes open for new ones.

The Agency for Healthcare Research and Quality guideline on pain can be obtained for free from their website (www.ahcpr.gov).

Three Enclosures on Pain Control

Enclosed with your introduction to palliative medicine at Good Samaritan is the pocket Handbook of Cancer Pain Management from David Weissman et al at the U of Wisconsin Medical School.20 Also you will find the laminated Principles of Pain Management Card.21. Finally, please find the case history deals with a 44-year old woman with terminal pain.22

Giving Sad News

There are no experts here. But there are suggestions, some of which are: give fair warning, sit quietly, listen carefully, acknowledge patient and family reactions, and give the opportunity for questions. Remember this is a person you are talking with--an individual with opinions, thoughts and life experiences far beyond what you know about them.23-25

"How long do I have, Doctor?"

Knowledge about prognosis for the underlying disease, and knowing its treatment options is an important--and often anxiety provoking--underpinning of talks with patients.

For cancer, a good resource that you can own is an inexpensive book, Clinical Oncology ($8.00 from the American Cancer Society 1-888-227-5552).26 Updates on clinical trials can be found online (CenterWatch, American Cancer Society, The James Center, National Cancer Institute, etc. Or, 1-800-4Cancer). All of these can supplement input from your clinical oncology team, and can be shared with your patient (more probably your patient has already given you the best web surfing tips).

For non-cancer diagnoses (such as dementia, COPD, AIDS, CHF) the National Hospice Association publishes invaluable, if imprecise, prognostic guidelines.27

Treatment Withdrawl--DNR Orders, Advance Directives

Again, there are no experts here. As always, the best approach is to talk with the individual, and listen to his or her thoughts. Being in hospice does not require a do-not-resuscitate status. The attached case history gets into some of these matters.22 Several reviews cover common principles, especially emphasizing patient autonomy. 28-31

(Withholding therapy or getting the DNR can lead to a reduction in societal resources consumed. But what are some implications of this economic bias? Are the savings significant? How does capitated healthcare financing influence withholding of care?)32-34

Websites

Search on any topic mentioned here, and you will get many hits. (Have you tried www.google.com for a search engine?) The National Hospice and Palliative Care Organization can be found at www.nho.org. (They also publish the book on non-cancer prognosis and hospice admission that is enclosed with this introduction).

For broader societal perspectives on death & dying, organizations focused on these issues are worth browsing. Two such sites are www.ABCD-caring.com (associated with the Robert Woods Johnson Project on Death in America), and www.lastacts.org. You can find numerous other sites.

Local Contacts

Pam McCabe, RN Hospice of Cinti 792-6944

Rebecca Bechhold, MD Hospice of Cinti 792-6944

Carl Gandola, MD Northside Health Ctr. 357-7600

Helen Koselka, MD Good Samaritan 872-3304

Candice Larkins Good Samaritan 872-3229

Hospice & Palliative Care Rotation: It is New--Help Shape It

Let us know what you think of this month: ideas, planning for next year, feedback about the experience. Most importantly, we hope you take away a keener interest in talking with your patients, and in remaining engaged in their care--giving each individual comfort & respect, even in the face of terminal illness.

On Your First Day

On your first day, go to Hospice of Cincinnati in Blue Ash. Meet Pam McCabe, RN or Linda Ruter, RN who will be your guide.

Bibliography

1. Doyle D, Hanks G, MacDonald N. Palliative Medicine. 2nd ed. NY: Oxford; 1999.

2. MacDonald N. Palliative Medicine: A Case-based Manual. 1st ed. NY: Oxford University Press; 1998.

3. Caroline N, Waller A. Palliative Care in Cancer. Boston: Butterworth--Heinemann; 1996.

4. Auden W. Miss Gee. In: Mendelson E, editor. As I Walked Out One Evening. First ed. New York, NY: Vintage; 1937. p. 96.

5. Moffat M. In the Midst of Winter. New York: Vintage; 1992.

6. Bone R. As I was dying: an examination of classic literature and dying. Ann Intern Med 1996;124:1091-93.

7. Nuland S. How We Die: Reflections on Life's Final Chapter. New York: Knopf; 1994.

8. Koenig B, Gates-Williams J. Understanding cultural differences in caring for dying patients. West J Med 1995;163:244.

9. Smith H. The Illustrated World's Religions: A guide to our wisdom traditions. New York: Harper Collins; 1994.

10. Geppert C. The rehumanization of death: the ethical responsibility of physicians to dying patients. JAMA 1997.

11. Butterfield P. The stress of residency. Arch Intern Med 1988;148:1428-34.

12. Levinson W, Dunn P. Coping with fallibility. JAMA 1989;261:2252.

13. Richman J, Flaherty J, Rospenda K, Christensen M. Mental health consequences and correlates of reported medical student abuse. JAMA 1992;267(267):692-94.

14. Wipf J, Pinsky L, Burke W. Turning interns into senior residents: Preparing residents for their teaching and leadership roles. Acad med 1995;70:591-96.

15. Rose VL. Guidelines from the American Geriatric Society target management of chronic pain in older persons. Am Fam Physician 1998;58(5):1213-4, 17.

16. Jacox A, Carr D, Payne R. Managemen of Cancer Pain. Clinical Practice Guideline #9: Agency for Health Care Policy and Research, US Dept of Health and Human Services; 1994.

17. Fohr S. The double effect of pain medication: separating myth from reality. J Pall Med 1998;1:3215-328.

18. NI C, RK P. Sedation in the management of refractory symptoms: Guidelines for evaluation and treatment. J Pall Care 1994;10.

19. Brietbar W, Marotta R, Platt M. A double blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium. Am J Psych 1996;153:231-37.

20. Weissman D, Dahl J, Dinndorf P. Handbook of Cancer Pain Management. 5th ed. Madison: University of Wisconsin; 1996.

21. Weissman D. MCW Palliative Care Program: Principles of Pain Management Laminated Cards; 1997. p. 1.

22. Foley K. A 44-year-old woman with severe pain at the end of life [clinical conference] [see comments]. Jama 1999;281(20):1937-45.

23. Creagan E. How to break bad news and not devastate the patient. Mayo Clin Proc 1994;69:1015-17.

24. Fallowfield L. Giving sad and bad news. Lancet 1993;341:476.

25. Ptacek J, Eberhardt T. Breaking bad news: A review of the literature. JAMA 1996;257:323.

26. Murphy G, Lawrence W, Lenhard R. Textbook of Clinical Oncology. Second ed: American Cancer Society; 1995. (Order from www.cancer.org $8.00)

27. Stuart B, Alexander C, Committee SaA. Medical Guidelines for Determining Prognosis in Seleected Non-Cancer Diseases. Second ed: National Hospice Organization; 1996.

28. Blackhall L. Must we always use CPR? N Engl J Med 1987;317:1281-82.

29. Meisel A, Kuczewski M. Legal and ethical myths about informed consent. Arch Intern Med 1996;156:2521-26.

30. Quill T, Brody H. Physician recommendations an the patient autonomy: Finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-69.

31. Waisel D, Truong R. The cardiopulmonary-resuscitation-not-indicated-order: Futility revisited. Ann Intern Med 1995;122:304.

32. Wenger NS, Pearson ML, Desmond KA, Harrison ER, Rubenstein LV, Rogers WH, et al. Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment [see comments]. Arch Intern Med 1995;155(19):2056-62.

33. Singer P. Rethinking Life and Death: The Collapse of Our Traditional Ethics. New York, NY: St. Martins.

34. Boyd K, Teres D, Rapoport J, Lemeshow S. The relationship between age and the use of DNR orders in critical care patients. Evidence for age discrimination [see comments]. Arch Intern Med 1996;156(16):1821-6.

Acknowledgements

Your hospice rotation is put together with the kind help of Pam McCabe RN, and Rebecca Bechhold MD both of Hospice of Cincinnati. Brenda Cain, RN got us off the ground our first year. Drs. Gandola, Koselka, Deak and Valle all serve on the TriHealth Palliative Care Committee that is chaired by Sister Agnes Coveney. Drs. Juan Carlos Mejia, and Leela Vrishabendrha also helped with the planning. Candice Larkin helps with logistics.

This document draws on copyrighted materials in, Improving End-of-Life Care: A Resource Guide for Physician Education, by DE Weissman and B Ambuel. (The Medical College of Wisconsin. 1999. Permission is pending.) TriHealth sponsored Drs Gandola & Mejia to attend the University of Wisconsin Faculty Development Course in End-of-Life Care, February 2000.

Please email comments and suggestions to:

cgandola@cinci.rr.com

Last update: 6/29/02; 6:23:33 AM.