News From the End of Life
Bush may reverse drug act
President Bush might issue an executive order that would undo the Clinton administration’s interpretation of a federal drug statute and block Oregon’s law allowing physician-assisted suicide, an Oregon senator says.
Sen. Gordon Smith (R-OR) said he discussed the order with Bush a few days after his inauguration, then followed up with a letter Jan. 25, hoping to ensure that Oregon doctors are not prosecuted retroactively.
At issue is the administration’s interpretation of the Controlled Substances Act, which regulates strong drugs, such as barbiturates. In 1998, former Attorney General Janet Reno ruled that the federal law did not apply to medicinal uses of listed drugs.
Reno’s ruling allowed Oregon doctors to continue prescribing lethal doses of controlled drugs to terminally ill patients. But Bush said during the campaign that he disagreed with Reno. Assisted suicide was not a "legitimate" medical use of controlled drugs, he said.
Opponents of physician-assisted suicide hope the recent confirmation of John Ashcroft as attorney general will lead to the overturning of Reno’s opinion. But Smith said Bush is more likely to move slowly and deliberately.
In his letter, Smith urged Bush to include three specific provisions if an order is issued. They are:
• assurances that federally controlled drugs can be used to treat pain, even in instances when their use might increase the risk of a patient’s death;
• expansions and modifications to the authority of the Drug Enforcement Administration not to include federally controlled drugs;
• prohibition of retroactive prosecutions of doctors who use federally controlled drugs in an assisted suicide.
The provisions listed in Smith’s letter coincide with the Pain Relief Promotion Act sponsored by Sen. Don Nickles (R-OK), which would amend the Controlled Substances Act to prohibit the use of listed drugs for assisted suicide. While a House version of this bill was passed, the Senate has not voted on it.
Hospital nurses don’t discuss hospice option
Although most hospital nurses say they provide comfort and support to their dying patients, more than half of the nurses in the hospital setting never discuss hospice care, a Yale study has found.
More than 80% of the nurses surveyed reported using a range of palliative care practices in caring for terminally ill patients in the hospital. However, more than half reported that they never discuss hospice with these patients. Further, many reported large gaps in knowledge about hospice and palliative care.
"These results underscore the importance of including curriculums related to the care of the dying in nursing programs," said Ruth McCorkle, director of the Center for Chronic Illness Care
in the Yale School of Nursing and a co-author of the study published in the February issue of the Journal of Professional Nursing. "The content needs to be integrated across nursing specialties and concentrated as core content that meets the standards of good practice. Hospice care is an important part of health care delivery today and all professionals need to be able to discuss it as an option for patients and their families."
The researchers surveyed 180 nurses at six randomly selected hospitals in Connecticut. Nearly two-thirds of the nurses surveyed had some hospice training, but less than 30% felt they were knowledgeable enough to discuss hospice care with patients. Many did not know when a patient can become eligible for hospice care and other basic information that might be needed by patients and their families considering care alternatives for their terminal illness.
The research suggests that there are significant gaps in knowledge about hospice among nurses in the acute care setting, while only a minority
of nurses feel capable of caring for terminally ill patients or knowledgeable enough to discuss hospice with those patients and their families, researchers concluded.
Patients not told about hospice
Researchers at Yale University have found that about 45% of terminally ill patients
are not receiving hospice services, according
to a report in the Dec. 22 issue of the Journal of Palliative Care.
Elizabeth Bradley, assistant professor in the Yale Department of Epidemiology and Public Health, and her co-authors evaluated the results of a cross-sectional survey of over 200 Connecticut physicians to determine the number of terminally ill patients who were referred for hospice.
"The study indicates that physicians refer only 55% of their eligible, terminally ill patients for hospice care and that many physicians lack knowledge about basic facts concerning hospice, such as patient eligibility criteria," says Bradley. "For instance, many physicians reported that
a patient must be expected to die within two months to be eligible for hospice, whereas the law states one must be expected to die within
six months to be eligible for hospice."
Physicians included in the survey gave many reasons for not referring patients to hospice care, including patient refusal or lack of interest; family refusal or lack of interest; and the physician’s own belief that hospice care was inappropriate or inapplicable, the Yale report adds.
"We saw that physicians’ knowledge level concerning hospice, board certification, and specialty were each independently associated with the proportions of terminally ill patients referred for hospice," says Bradley. "One unexpected finding was that having had previous training regarding hospice care was not associated with improved knowledge of hospice or increased propensity to refer patients for hospice care. While it’s possible that specific types of training do affect physician knowledge and/or behavior, our findings reveal that physician training, as measured broadly in this study, may not influence physician knowledge regarding hospice or physician referral practices substantially."
The Yale researchers say the results offer information that can be used to develop interventions and educational efforts aimed at improving physician knowledge about hospice care, resulting in increased hospice care referrals.
Geographic variation in hospice use
Fifteen out of every 100 deaths in the United States occurred in a hospice setting, according to a study published in the Dec. 21 issue of the Journal of the American Geriatrics Society.1
Demographic characteristics such as age, race, and area income influenced hospice utilization. Specifically, younger people, black people, people from wealthier areas, and patients who paid their own Medicare premiums were more likely to use hospice services before death.
Researchers analyzed 1996 Medicare and hospice data. They looked at the use of hospice within geographic constructs known as hospital service areas, which are local units of health care services based on ZIP codes. There are a total of 3,436 hospital service areas in the United States. The researchers analyzed the impact on hospice utilization of managed care markets, the number of hospital beds and physicians, reimbursements, and the number of in-hospital deaths in the area.
Although the national rate of hospice use averaged 10.9 hospice users per 100 deaths, the rates were higher in urban areas than in rural areas (15.6 vs. 11.4). Some areas of the country had rates as high as 25 per 100, while in others the rate was less than 10 hospice users per 100 deaths.
Portland, ME, had the lowest usage rates (3.5), and comparatively low rates were found in New York City and Albuquerque, NM. The highest rates were in Denver (28.6), Phoenix (30.3), and Ft. Lauderdale, FL (39.7).
Cancer patients use hospice the most, but in areas of high hospice use, non-cancer patients are also well-represented. In addition, hospice use is lower in areas where there are higher rates of in-hospital deaths.
In areas where a large proportion of the population is enrolled in HMOs, hospice use is high, but not only among the HMO enrollees. Where health care reimbursements are higher and there are greater numbers of physicians available, hospice use also is higher, regardless of patient characteristics.
The authors concluded that all of these variations suggest "tremendous potential for growth of the Medicare hospice benefit." Its use could increase by 15,000 or even 250,000 individuals per year. Increased hospice use is not by itself a necessary goal, but a variety of factors would influence how its growth might occur.
Reference
1. Virnig BA, Kind S, McBean M, Fisher E. Geographic variation in hospice use prior to death. J Am Geriatr Soc 2000; 48:1112-1117.
Periodical offers CME and CEU credit
Physicians can receive 1½ prescribed credit hours from each bimonthly issue of the American Journal of Hospice & Palliative Care. The content of the program was approved by the American Academy of Family Physicians (AAFP).
A full-year subscription can yield 9 of the required 30 hours of CME credit.
Currently, credit is available for board-certified family physicians through the AAFP and reciprocally through the American Medical Association. The Journal has applied for approval for accreditation from other clinical specialties, including hospice and palliative medicine.
The American Journal of Hospice & Palliative Care, founded in 1984, is the oldest peer-reviewed, multidisciplinary professional journal devoted to hospice, palliative medicine, pain and symptom management, and end-of-life care.
Subscription to the journal is $174 per year. To receive 1½ CME credit hours or continuing education units (CEUs) for reading the journal, physicians must complete and mail the post-test printed in each issue. The physician will receive a CME/CEU certificate in the mail after successfully completing the post-test with a passing score of 70%.
Funding boost may aid telemedicine expansion
In the flurry of changes to the health care budget bill passed by Congress late last year, lawmakers passed legislation increasing Medicare reimbursement for telemedicine services.
Among other things, the bill:
• expands eligible service areas for covered telemedicine services from restricted rural health shortage communities to include all non-metropolitan counties and existing urban Medicare demonstration sites;
• expands the services that can be billed to Medicare;
• eliminates a required fee splitting requirement between presenting health professionals at the local and referring sites;
• includes a new $20 facility fee;
• keeps in place existing Medicare reimbursement for teleradiology, remote cardiac monitoring and related services that are available throughout the country.
The provisions are scheduled to go into effect Oct. 1.
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