The
First International Geriatric and Palliative Care Conference
INVITED SPEAKERS' SUMMARIES
PALLIATIVE CARE AS A HUMAN RIGHT
G.J. Annas, Boston University School of Public Health, Boston, MA, United States
I will briefly explore the nature of human rights, including what it means to have a right, and compare and contrast this concept with the concept of constitutional rights. The contrast will be set in the context of the U.S. Supreme Court decisions, Compassion in Dying, and Quill, and will focus on the nature of the right to physicianassisted suicide asserted (and rejected by the Court) in that case. Finally, I will review what the Justices had to say about the "right not to suffer" and how this right can be seen as creating an obligation on the part of physicians to provide decent palliative care to their patients. After the presentation attendees should be able to compare and contrast human rights and constitutional rights, distinguish between so-called negative and positive rights, define a right not to suffer, and debate ways in which such a right can be asserted and enforced.
COMMUNICATION SKILLS
P. A. Bloom, St. Luke's-Roosevelt Hospital Center, New York, NY, United States
This presentation will convey, in an interactive format, a number of communication skills necessary for communicating with patients and families about palliative care issues. Emphasized issues will be communication techniques and their relationship to the health care professional's personal perspective on death and dying; empowerment of patients and families; and the influence of cultural/ethnic factors on personal preferences concerning death and dying.
GASTROINTESTINAL SYMPTOMS
L. J. Brandt, Division of Gastroenterology, Montefiore Medical Center/AECOM, Bronx, NY, United States
Dysfunction in any organ system manifests with only a limited number of symptoms. Thus, what appears to be the same disease process in disparate age groups may reflect different etiologies of disease. Differential diagnoses in the elderly may be more complex than in a younger population because of the varied presentations of certain diseases in the elderly, complications that only occur after many decades of disease, and altered responses of the aged host. The educational objectives of this presentation are:
i. To review the usual gastrointestinal symptoms and their causation in the elderly as compared with a younger population.
2. To acquaint the audience with the means to evaluate these symptoms and
arrive at a management plan.
W. Breitbart, Memorial Sloan-Kettering Cancer Center, New York, NY, United States Learning Objectives: After this lecture, the palliative care practitioner should be better able to:
1.Discuss delirium as a common neuropsychiatric complication of advanced disease. 2 Describe the proper assessment, diagnosis and management of delirium. 3 Discuss how the proper management of delirium is important in minimizing morbidity and improving the quality of care
THE AMOREXIA-CACHEXIA SYNDROME______________________________ E. Bruera, University of Texas, M.D. Anderson Cancer Center, Houston, TX, United States Anorexia-cachexia is one of the most common problems in palliative care patients. In diseases such as cancer and AIDS this syndrome is mostly due to metabolic abnormalities due to host cytokines and tumor by-products. In other geriatric populations and a minority of cancer patients, poor oral intake also has a role. The clinical manifestations include anorexia, asthenia, chronic nausea, and changes in body image. The role of artificial nutrition and pharmacological interventions will be discussed focusing mostly on cancer cachexia. Counseling is of great importance because of the strong psychological and religious significance of food for most cultures. Areas for future research in this subject will be recommended.
CHRONIC OBSTRUCTIVE PULMONARY DISEASE; THE CASE OF John DOE D. Budnick, A. Dormer, EvenCare, Brooklyn, NY, United States At the end of this presentation participants will be able to:
1. Identify patients with terminal Chronic Obstructive Pulmonary Disease 2. Address medical and social issues that should be discussed with patients and families 3. Outline appropriate treatment and symptom control
ALZHEIMER'S DISEASE____________________________________________ J. Carter J. Morris Jewish Home and Hospital, New York, NY, United States, (2) Mount Sinai Medical Center, New York, NY, United States Alzheimer's disease is a catastrophic illness for both patient and caregivers. The irreversibility of cognitive and functional decline poses difficult and frequently changing challenges to health care providers faced with providing excellent primary care. The educational objective of this session is to outline common problems and means to integrate palliative care principles into the plan of care.
ETHICAL ASPECTS: A FOCUS ON CLINICAL RESEARCH
D. Casarett, Division of Geriatrics, University of Pennsylvania, Institute
on Aging, Philadelphia, PA, United States Research to improve end-of-life
care is essential, but this research poses considerable ethical challenges.
In order to better understand and address these challenges, this presentation
will summarize empirical data from two studies:
1) a qualitative study to define the research risks and benefits that are
most important to patients near the end of life; 2) a nationwide study to
evaluate the procedures for informed consent and human subjects' protection
that are employed by hospices that participate in research. Implications for
the ethical design and conduct of palliative care research will be discussed.
AGING, GERIATRICS, AND PALLIATIVE CARE
C.K. Cassel, Mount Sinai Medical Center, New York, NY, United States Participants will learn to identify end-of-life needs of older adults and strategies for improving their quality of life. Because death in old age often follows a period of progressive functional decline, an appropriate model of care may simultaneously provide some kinds of life-prolonging care as well as palliative and personal care. Physicians need to understand the principles ofgeriatric medicine as well as palliative care.
AMXIETYAND DEPRESSION________________________________________ H. M. Chochinov,
University of Manitoba, Department of Psychiatry, Winnipeg, MB, Canada
This presentation will provide an overview of the complex emotional responses
elderly patients experience as they approach death. Various facets
of this response including depression, loss of hope and a wish for hastened
death - will be discussed, using both research data and clinical experience.
TEAM BUILDING
N. Coyle B. Mamber Memorial Hospital, Beth Israel Medical Center,
NY, New York, United States
Developing and maintaining an effective team is an essential component of
Palliative Care. This presentation will identify the underlying principles
of successful team building and demonstrate the effectiveness of palliative
care teams in long-term care facilities.
ASSESSMENT AND MANAGEMENT OF BREATHLESSNESS_____________ D. Dudgeon, Queen's University, Kingston, ON, Canada Dyspnea greatly affects the quality of life of many of our patients. It often goes unre ognized and untreated until the person is short of breath at rest. During this sessio participants will learn the multidimensional nature and assessment of dyspnea, tl pathophysiology, and current treatment strategies.
ASSESSMENT OF PAIN IN ELDERLY PERSONS________________________ B. Ferrell, University of California at Los Angeles, Los Angeles, CA, United States At the conclusion of the educational experience, participants will be able to:
1. Evaluate pain in elderly patients accurately and reliably.
2. Understand limitations of pain assessment in elderly persons with cognitive
impairment.
3. Understand the rationale for pain assessment on a routine and regular basis, including the concept of "pain as the 5th vital sign."
4. Understand the limitations of pain assessment by proxy, caregivers, and health ca professionals.
PALLIATIVE CARE IN A TERTIARY CARE CENTER
D. Fischberg, Mount Sinai Medical School of Medicine, New York, NY, United States Following this presentation attendees will be able to: i) Describe the history of hospital-based palliative care.
2) Understand the clinical and educational imperatives for hospital-based
palliative care.
3) Understand the potential for clinical impact of a hospital-based palliative
care program through a quantitative review of data from the Palliative Care
Service at Mount Sinai Hospital.
PALLIATIVE CARE FOR MARGINALIZED POPULATIONS________________ A. Fox, University of Pittsburgh, Pittsburgh, PA, United States
"Marginalized populations" can include cognitively impaired older adults, peop with psychiatric illness, those who resist or are distrustful of care, minorities, the po' and the very young. Attendees at this session will learn about issues specific to ma ginalized populations at the end of their lives and why traditional approaches of pc liative care may not address their needs. Creative approaches to the care of marginc ized populations will be stressed.
TO DEVELOP AN ACADEMIC GERIATRIC PROGRAM: INFRASTRUCTURE FOR A SUCCESSFUL PROGRAM IN GERIATRIC PALLIATIVE CARE_________ W. R. Hazzard, VA Puget Sound Health Care Systems, Seattle, WA, United States For a program in geriatric palliative care to have maximal impact, it must be embedded in an academic geriatric program with strengths in research, education and model clinical care. General principles of successful academic geriatric program development will be reviewed, as drawn from experiences at three academic health centers: University of Washington, Johns Hopkins University, and Wake Forest University.
PROVIDING CARE AT THE END OF LIFE: AN ASSESSMENT OF MEDICARE COVERAGE AND REIMBURSEMENT METHODS________________________ H. A. Huskamp, Harvard Medical School, Boston, MA, United States This session will provide a brief overview of Medicare coverage and reimbursement methods for end-of-life care, describe issues raised in structured interviews by endof-life care providers regarding Medicare coverage and reimbursement, and discuss options for addressing these issues.
THE ABCS OF EVIDENCE-BASED DECISION MAKING___________________ A. Jadad, Director, McMaster Evidence-based Practice Center, McMaster University, Hamilton, Ontario, Canada Participants will learn about: The basic principles and tools of evidence-based decision making (EBDM). Barriers that limit the impact of EBDM on "real world" decisions. Current strategies for overcoming these barriers. Challenges for geriatric palliative care.
METHODOLOGICAL CHALLENGES
S. Kaasa, University Hospital ofTrondheim, Trondheim, Norway
There is a need for evidence-based medicine to improve patient care. Knowledge from studies must be combined with the best clinical experience. In palliative care in general, challenges to conducting clinical trials are related to the patient population (elderly, multiorgan failure, multiple symptoms, polypharmacy, cognitive failure, etc.). In most studies, improvement or maintenance of quality of life, symptom control and the quality of psychosocial support are the primary aims. Valid outcomes for use in the elderly population during end-of-life care are few; ethical challenges, study design, and outcome measures will be the focus of this presentation.
PALLIATIVE CARE IN JAPAN AND PACIFIC RIM COUNTRIES______________ T. Kashiwagi, Osaka University, Osaka, japan The first hospice in Japan was started in 1981 and we now have 75 hospices. The presentation will be focused on hospice care in Japan and the activities of Asia Pacific Hospice Palliative Care Network.
PSYCHOSOCIAL CRISES___________________________________________ J.Kennedy, Albert Einstein College of Medicine and Division of Geriatric Psychiatry, Montefiore Medical Center, Bronx, NY, United States The psychosocial issues in the palliative care of older adults are both simple and more complex than those associated with younger terminally ill persons. For the older person, chronic illness and long-term care often prepares the patient and caregivers for the terminal event. And death is the expected outcome of advanced age. However, the diminished social networks and impaired cognition that older persons experience make emotionally supportive care more difficult. Ethnic and cultural differences between caregivers and patients further complicates the mix.
COMGESTIVE HEART FAILURE______________________________________ R. D. Kennedy, Maimonides Medical Center, Brooklyn, NY, United States
The need for palliative care in in terminal CHF increases with the rise in age adjusted death rate from this condition. When medical and surgiacal treatment is exhausted,symptomatic relief in terminal heart care is a major challenge for the healthcare team. Factors contributing to management problems and strategies suggested. In terminal concestive heart failure increases with the rise From this condition. When medical and surgical treatment : relief in terminal heart failure is a major challenge for the contributing to management problems will be discussed Attention to dvsonea. cardiac oain. coueh and anxietv will
CORE CURRICULUM FOR MEDICAL DIRECTORS; INTRODUCTION________
M.J. Koren, The Fan Fox & Leslie R. Samuels Foundation Inc., New York,
NY, United States
Palliative care is typically associated with end-of-life care. However, its precepts and principles can improve not only the lives of the terminally ill but also those compromised by severe chronic disease. This session will discuss important elements for successful implementation of a palliative care program in long-term care settings.
CAREGIVERS; SILENT MEMBERS OF THE PALLIATIVE CARE TEAM_______
C. Levine', M. Glajchen\ 'Families and Health Care Project, United Hospital
Fund, 'Beth Israel Medical Center, New York, NY, United States
This presentation will describe the current state of knowledge about family
caregivers for elderly people who are ill and disabled, and what kinds of
programs and services these caregivers need. It will draw upon new survey
data, focusing on the medicalized tasks that caregivers are expected to perform,
and the training and emotional support they need. It will stress the responsibilities
of health care professionals and institutions in this effort.
PALLIATIVE CARE INITIATIVES IN LONG-TERM CARE AND NURSING EDUCATION____________________________________________________________ M. Mezey, New York University School of Education, Division of Nursing, New York, NY, United States This presentation addresses palliative care needs of older people in long-term care settings, highlights promising initiatives in palliative care management in long-term care, and describes nursing education's efforts to assure that nurses effectively manage palliative care needs of long-term care residents.
EVOLVING VIEW OF QUALITY CARE IN NURSING HOMES: IMPLICATIONS OF AN AMERICAN
EXPERIENCE WITH HOSPICE CARE IN NURSING HOMES__________________________________________________________
S. C. Miller, Brown University, Providence, Rl, United States At the conclusion
of this presentation attendees will be able to:
1. Discuss findings from recent hospice in nursing home studies; 2. Describe
the use of computerized resident assessment data for research; and 3. Discuss
the implications of the above in relation to improving quality of care for
dying nursing home residents.
PHARMACOLOGIC APPROACHES____________________________________ R. K. Portenoy, Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, NY, United States
As in all pain populations, the ability to competently provide analgesic drugs is one of the essentials of pain management in the elderly. This presentation will update health care professionals on the indications for and use ofopioid and adjuvant analgesics in the geriatric population.
DELIRIUM IN PALLIATIVE CARE______________________________________ K. Rockwood, Dalhousie University, Halifax, NS, Canada Recognizing that death sometimes is accompanied by clouding of consciousness, patients who are dying commonly express the desire to be of clear mind for as long as possible. My presentation will discuss how to describe this clouding of consciousness, whether it is preventable or treatable, which factors are most associated with it, and how it relates to delirium in its classical conceptualization.
HOSPICE AND PALLIATIVE CARE IN THE SKILLED NURSING FACILITY R. Schonwetter, MD, CMD, LifePath Hospice, Tarnpa, FL, United States
Although new palliative care programs are emerging, hospice has become the major delivery system for end-of-life services in nursing facilities in the United States. Recent literature has described outcomes of hospice care in these facilities. This presentation will describe potential benefits and challenges of providing hospice services in nursing facilities and discuss barriers to accessing these services.
PALLIATIVE CARE IN A FRENCH HOSPITAL-BASED GERIATRIC SERVICE - A PERSONAL
JOURNEY______________________________________________ R. Sebag-Lanoe, Service
de Gerontologie et de Soins Palliatifs, Hopital Paul Brousse Villejuif, Paris,
France
For the last twenty years, our team has illustrated the importance of introducing
a practice of palliative care in geriatric hospital institutions, trying
to respond to patients', families' and professionals' suffering, and thus
organize an efficient prophylaxis of wishes and practices of euthanasia. We
have built our experience on ethical and anthropological necessities through
psychoanalysis and psychoanalysts.
PRINCIPLES OF SYMPTOM ASSESSMENT AND THERAPY II_____________ L Shaiova,
MD, Beth Israel Medical Center, New York, NY, United States (Saturday, October
14'h, 4:10 p.m. - 4:40 p.m.)
Pain and dyspnea are two of the most prevalent symptoms in the medically-ill
elderly. This presentation will 1) identify the appropriate assessment
techniques for pain and dypsnea in this population; 2) discuss pharmacologic
approaches for these symptoms; and 3) explore non-pharmacologic options for
treatment.
PALLIATIVE CARE...EVERYWHERE___________________________________ R. K. Steel,
Hackensack University Medical Center, Hackensack, NJ, United States
Given the aging of the world, the need for a standardized reliable valid
means of assessing the palliative care needs of elders in all sites of care
is of paramount importance. Therefore, this presentation has the following
objectives: i) to provide information about InterRAI, Inc., a not-for-profit
research group presently designing and implementing a palliative care instrument;
2) to demonstrate how a "comprehensive" assessment might be designed to include
palliative care needs; 3) to demonstrate how data can then be grouped to
allow for comparisons across sites of care and even nations.
NONPHARMACOLOGIC INTERVENTIONS FOR PAIN IN THE ELDERLY
W. M. Stein, San Diego Hospice, San Diego, CA, United States
This presentation will focus on the studies performed to date involving nonpharma
cologic interventions for pain in the geriatric population. As this is a
relatively little explored frontier in pain management, the best study or
descriptive information avail able in each major area will be discussed and
will include topical analgesics, physica therapy and related modalities,
chiropractic, acupuncture, thermal interventions, cog nitive therapies, and
other complementary therapies.
DIGNITY AND FORGIVENESS_______________________________________ D. P. Sulmasy, Department of Ethics, Saint Vincent's Hospital and Medical Center, New York, NY, United States (Saturday, October 14thl 8:10 a.m. - 8:40 a.m.) This presentation will bring the audience to a deeper understanding of the comple) concept of dignity, particularly as it relates to the processes of aging, illness, anc death, and to understand forgiveness as a human and spiritual act that vivifies anc reverences the mutual dignity of finite persons.
NEOPLASTIC DISEASE
D. 1. Wollner, R. A. Indelicato, Beth Israel Medical Center, New York, NY,
United States
Neoplastic diseases are the second largest cause of death in older persons.
This session will: i) review the epidemiology and etiologic theories of cancer,
2) develop general palliative care principles for this population, 3) describe
management of metastatic disease for the 3 commonest cancers in the elderly
and, 4) use case-based teaching to highlight palliative care approaches to
the elderly with advanced neoplastic diseases.
THE IMMINENTLY DYING AND THE ROLE OF HOSPICE_________________
D. 1. Wollner, Beth Israel Medical Center, New York, NY, United States
Most elderly die in hospitals and nursing homes. End-of-life care is usually
poor. Pain is undertreated, advance directives are ignored, and life's last
days are tethered to medical equipment. This presentation will: i) identify
the clinical factors that define who the imminently dying are; 2) explore
the interdisciplinary approach to assessment and treatment when life's end
is near; 3) discuss management of intractable symptoms; 4) explore caregiver
and staff bereavement issues; and 5) emphasize factors that hospice care
can provide in skilled nursing facilities for the imminently dying.
The Frail Elderly
J. Zeleznik, C. Smyth, Montefiore Hospital, Bronx, NY, United States
A discussion of the operational definitions of frailty and evidence for a
biologic phe nomenon which impacts on the functional, physiological, spiritual,
and sociologicc dimensions of some older adults. Case vignettes will be used
to explore frailty from the patient';s, caregivers, and healthcare providers'
viewpoints.
AUTONOMY AND ADVANCE DIRECTIVES: A BLUEPRINT FOR THE FUTURE
C. Zuckerman, White Plains, NY, United States
Advance directives can be useful legal tools to support patient autonomy at the enc of life. However, such directives usually reflect a limited view of autonomy placed ir the technology driven hospital setting. As palliative care becomes part of the care continuum, and as more geriatric patients reflect a pattern of gradual decline before death, such directives need to better capture the diverse array of late life situations and need a more encompassing concept of autonomy, including a portrait of autonomy that reflects the paytients connection to intimate others.
POSTER PRESENTATION ABSTRACTS
i. ACUTE CONFUSION IN HOSPITALIZED ELDERLY PATIENT
S. M. Bond, V. Neelon, M. j. Belyea, UNC-CH School of Nursing, University of Nort Carolina at Chapel Hill, Chapel Hill, NC, United States
Purpose of the Study:
To evaluate changes in acute confusion (AC) in hospitalized elderly patients
over time from admission to discharge.
Description:
Data were obtained from a convenience sample of 158 elderly patients admitted
to a tertiary medical center. The NEECHAM Confusion Scale (i) was used to
measure AC at the time of admission, on a daily basis throughout hospitalization,
and at discharge. A number of patients (39%) exhibited AC on admission. A
larger number (63%) experienced AC during hospitalization. A repeated measures
ANOVA was used to evaluate changes in AC over time. Mean NEECHAM score decreased
from 23.93 (SE + .416) a1 admission to 21.31 (SE + .552) at its low during
hospitalization, and increased to 25.27 (SE + .333) at discharge. Differences
between NEECHAM score on admission and lowest NEECHAM score during hospitalization
(F(i,io8) = 54-321, P <:•••• -oooi), and between lowest NEECHAM score
during hospitalization and NEECHAM score at discharge (F(i,io8) = 93-491,
P u····· -oool) were statistically significant.
Conclusions:
Acute confusion is common in elderly patients and varies in severity over
hospitaliza tion. Because AC is associated with an increased risk for dementia
and death (2), earl\ identification and treatment is important to prevent
adverse consequences.
References:
i) Nursing Research 1996; 45 324-330 2) Age and Ageing 19991 28 551-556
2. NPs PALLIATIVE CARE KNOWLEDGE AND THEIR PERCEIVED SKILL LEVEL IN THE US________________________________
D. W. Bucknill, J. A. Beal, P. A. Rissmiller, Simmons College, Graduate School for Health Studies, Boston, MA, United States
Purpose of the Study:
To explore the actual and perceived knowledge of palliative care and the
perceived level of skill in a nationwide random sample of American Nurses
Credentialing Centel certified NPs from all NP specialties.
Description:
This descriptive, correlational study assessed the actual and perceived knowledge
ol palliative care, pain management, death and dying, communicative skills,
symptom control and their perceived level of skill according to Benner's
theory of nursing skill acquisition - novice, advanced beginner, competent,
proficient and expert
Conclusion:
The NPs perceived knowledge was greater than their actual knowledge and the
majority perceived themselves as novices or advanced beginners in their palliative
care skill level. As primary health care provides, NPs should be included
in palliative care educational forums in order to provide their terminally
ill patients and families with expert palliative care.
References:
Benner, P. (1984). Novice to Expert: Excellence and power in clinical nursing
practice. Menlo Park, CA: Addison-Wesley Publication Co.
National Hospice and Palliative Care Organization (1998). Guidelines for
curriculum development on end-of-life and palliative care in nursing education.[Brochure].
Arlington, \/A: author
Arlington, VA: Author 3. INTERFACE BETWEEN PALLIATIVE CARE AND GERIATRICS
Claudia Burla, M.D., Rio de Janeiro, Brazil
Aging is a natural, progressive and declining biological process. It is marked by physiological changes that make the body prone to the development of diseases, as there is a major shift from an anabolic to a catabolic status. Chronic and degenerative diseases are impairing and cause intense suffering until death to the patient and his family due to a total lack of organic reserves.
Death is a natural event in life, but in the elderly there are a number of conditions that severely compromise their autonomy and independence. The associated symptoms may or may not cause suffering. However, it is the core of a good geriatric practice to relieve any distressing symptoms a patient may present. There often is physical, mental, and emotional suffering until death.
Based on the principles of Palliative Medicine, we propose a specific approach to the conditions presented by the elderly in late stages of any chronic and degenerative disease, in order to rationalize the use of symptom relieving drugs and set guidelines for the proper health care to this population, assailed by cognitive, sensorial, and functional impairments, and the failure of major organs. Any specific therapeutic decision will have an impact on the overall palliative care measures, and the "iceberg phenomenon" is a major challenge for geriatric physicians, whose main focus should be the provision of a good quality of life.
The proper use of drugs in tandem with a multiprofessional team acting
on an interdisciplinary basis will be decisive for the quality of care a
patient receives at the final
et-inn nt l»;- l:c-
ft~ THE USE OF HOSPICE SERVICE IN DEMENTIA PATIENTS______________ R.K. Chhablani*, M.J. Gorbien*, K. Nash**, *Rush Medical College, Section ofGeriatric Medicine, **Rush College of Nursing, Chicago, IL, United States
Purpose of the study:
The use of hospice services in patients (pts.) with Alzheimer's Disease (AD)
& other primary progressive dementias is an area in end-of-life care
which has been inadequately studied. Our goal was to review cases referred
to one, large home-hospice organization to better understand the patterns
of utilization for this group of pts.
Description:
We reviewed the 1996-99 charts of hospice pts. with the primary diagnosis
at death of dementia, AD or organic brain syndrome. We collected data regarding
age, gender, location of death, referral source, gender, race, religion, duration
of stay in hospice, presence or absence of a surrogate decision maker and
advance directives. 152 charts were reviewed, (n=i52).
Conclusions:
The average age of the study group was 85 years (52-107). We found that the
majority were female (76%), single (70%) and Caucasian (78%). 18% withdrew
from hospice due to improved health or change in wishes. 70% had an advance
directive. The average duration of stay was 43 days. 12% died within the
first day, 36% died within a week, 59% died within 2 weeks, ioo% were dead
in 6 months. Referral sources included hospital (38%) & nursing home
(30%). It was common for family & home health workers to contact the
hospice directly, with subsequent physician contact. This study supports
the concept that there is room for improvement in the use of palliative services
for pts. suffering from late stage dementias. Similar to cancer, referrals
for dementia patients are likely to come in the last few days of life. Through
better education & awareness, hospice service can be used more often
& earlier so that patients & families can benefit from this style
of care.
5. FAMILY BEREAVEMENT SUPPORT: DEVELOPING AN EVIDENCE-BASED PROGRAM_______________________________________________________
K.M. Davidson, Palliative Care Advisor, Bethany Care Society, Calgary, AB, Canada
Purpose of the Study:
To evaluate the effectiveness of a bereavement support program for family
members of residents who died in a Bethany Care Society long-term care centre.
From the evaluation data, an evidence-based best-practice guideline for bereavement
support was developed.
Description:
The literature is replete with books and journal articles detailing the process
of grief and bereavement, and with suggested interventions for assisting
clients through the bereavement period. However, the literature is almost
silent on the evaluation of bereavement support interventions and programs.
Other than anecdotal reports, very little evidence is available to guide
the development of bereavement programs, and there is equally sparse evidence
to support the choice of one grief support intervention over another.
Bethany Care Society has 750 long-term care residents living in four centres in the Calgary region. This paper describes an evaluation of our bereavement support program. An internal committee examined our current bereavement support practices. A brief questionnaire for bereaved family members was developed, pilot-tested, and a telephone survey was conducted. In addition, other care centres in the Calgary region were surveyed regarding their bereavement program.
Conclusions:
Based on this evidence and the available literature, Bethany Care Society
developed and implemented an evidence-based Bereavement Support Guideline,
to ensure all our bereaved families receive consistent, useful grief support.
6. DEATH AS A FUNCTION OF AGE, RACE, AND GENDER ON AN INPATIENT PALLIATIVE CARE UNIT__________________________________________
A.N. Galanos, N. Lang, I.C. Hays, M. Carman, T. Cutson, H.K. White, C.F. Pieper Duke University Medical Center, Durham, North Carolina, United States
Purpose of the study:
To describe the demographics of referrals to an inpatient palliative care
unit, and their impact on deaths on the unit.
Description:
The data come from the screening/referral form for the Palliative Care/Transitional
Care Unit at a tertiary care, academic medical center. A total of 162 adults
were referred for Palliative Care with a mean age of 69.6 years (range =
24-100). Of those referred to the unit, 55% were female and 45% were Black.
The average length of stay for a palliative care patient was only 5.4 day.
Deaths on the unit were examined as a function of age, gender, and race over
a one-year period. Of the 85 deaths that occurred on the unit, the
rates did not differ between blacks and whites nor between men and women.
However, death on the unit increased linearly by age (P.5~-o.oool).
Conclusions:
Even on an inpatient palliative care unit with a seriously ill population
from a tertiary care hospital with a short length of stay, age remained a
significant factor in mortality. Factors such as timing of referral
for older patients, potential for Hospice, and preferences for place of death
need further study.
7. ARE YOUNG-OLD ADMITTED TO A PALLIATIVE CARE UNIT DIFFERENT
FROM THE OLD-OLD?
A.M. lzquierdo-Porrera, University of Maryland, Baltimore, MD, United States
Purpose of the study:
To determine whether differences exist between young-old and old-old referred
to a ' Palliative Care Unit.
Summary description of the project: Rptrntinprtive review of 2000 charts of
patients 6s or older referred to a Palliative Care
Unit. Comorbidities; current neoplastic disease: months since diagnosis, number
of )I days of PCU follow-up before death; symptoms:
drug use and social support were UI recorded. Patients
age 65 to 74 were compared to those 75 and older. Both groups
g
were significantly different with respect to cardiologic comorbidities ~p=o.oi), Disease of the senses (0.031), tobacco consumption (p=o.03), alcohol consumption (p=o.008), drug administration routes (p=o.025), having a significant other (p=o.oo3), and who the primary care giver was (p=o.oo3). There were non-significant differences with respect to months since diagnosis, number of days of PCU follow-up before death, symptoms or place of death.
Conclusions:
Older-old have a significantly higher number of comorbidities, but are not
referred to the palliative care unit at an earlier time in the progression
of the disease. No age bias seems to exist with respect to referrals to the
Palliative Care Unit.
References:
i) Campion EW. The Oldest old. N Engl J Med. 1994 Jun 23;330(25):1819-2000
2)Jenkins CA, Taube AW, Turner K, Hanson J, Bruera E. Initial demographic, symptom and medication profiles in patients admitted to continuing palliative care units. J Pain Symptom Manage 1998; 16 (3): 163-170
3) Cleary JF; CarbornePP. Palliative medicine in the elderly. Cancer 1997;80
(7):
1335-1347
8- PREDICTING DEATH IN A PACE PROGRAM
M.A. Lee, M. McMahon, L Skokan, K. House, V. Skakel, I. Meyer, K. Brummel-Smith, Elder Place and Center for Outcomes Research and Education, Providence Health System, Portland, OR, United States.
Purpose of the Study:
To describe death and dying and evaluate end-of-life care in Elder Place,
a Program of All-Inclusive Care for the Elderly (PACE) site.
Description:
We retrospectively reviewed the medical records of all participants who died
between June 1996 and May 1999 (n=i8o).
Conclusions:
Death was anticipated and care plans modified accordingly for the majority
of this frail group of patients (mean age at death, 84 yr.). 68% were recognized
to be in the process of dying for days/wks prior to death, 20% had been gradually
declining, but not recognized to be dying, 6% died as a result of a known
acute illness, and 6% died suddenly and unexpectedly. Marital status was
related to the circumstances surrounding death, with married participants
the most likely to be recognized as being in the process of dying. Having
a durable power of attorney for health care was positively correlated with
recognizing the dying process; a positive self-report of health status within
4 months of death was negatively correlated. Regression analysis was used
to identify variables that would predict the circumstances surrounding a
participant's death, i.e. recognized dying process versus sudden, unexpected
death. Although no single variable was a significant predictor, the 12 variables
in the model explained 41% of the variance. We conclude that death can be
anticipated and palliative care delivered for most frail older persons, even
in the absence of known terminal illness.
References:
i) JAMA 2000'283:512-518.
2) J Palliat Med 1999)173-184
9. PHYSICAL REHABILITATION IN A HOSPITAL BASED PALLIATIVE CARE UNIT___________________________________________________________
M. Lodhi, M. Montagnini, P. Millington, Zablocki Veterans Affairs Medical Center and Medical College of Wisconsin, Milwaukee, Wl, United States
Purpose of the Study:
Little is known about the utilization of rehabilitation interventions in
palliative care settings. Our aim is to describe the use of physical
therapy (PT) in terminally ill patients.
Description:
The study consisted of a retrospective chart review of ioo patients (mean
age 70 y, 96% males) discharged from the Zablocki VAMC Palliative Care Unit
from Oct 1998 to Dee 1999- We assessed the rate of utilization of PT services
and evaluated functional gains, using a modified KATZ score, in patients
who received PT. Data was obtained from the Minimum Data Set and PT notes.
Thirty-seven patients received a formal PT assessment, in this group, the
degree of disability using the KATZ score was 60% for transfers, 56% for
walking and 56% for toileting. Eighteen patients received PT primarily for
deconditioning (66%), imbalance (ii%) and focal weakness (ii%). Treatment
modalities included endurance exercises, gait training, functional exercises
and therapeutic exercises. The time span of the PT program was 8.6 days (range
i319 days). Six patients (33% of those treated) reached their functional goals
and improved on the KATZ mobility score. PT was discontinued in 12 patients
due to generalized weakness and disease progression.
Conclusions:
In summary, PT assessment is uncommon among terminally ill patients.
PT assessment does document potentially remediable deficits. PT is employed
sparingly, but can benefit a subset of patients. Disease progression does
interfere with desired outcome. The role of PT in the terminally ill needs
better definition.
10. NONCANCER DEATH AND PALLIATIVE CARE IN THE ELDERLY_________ M. Lungu, C. Bogdan, St. Luke Hospital, Bucharest, Romania
Purpose of the study:
To search for specifics of palliative geriatric care, studying the observations
and circumstances leading to the death of 237 old people hospitalized in
Geriatric Hospital.
Description:
It is a retrospective study of 237 Patients' Records of old people who died
between 1996-1999* among them 42 % supervised in extended geriatric care
department through a palliative approach. The collected data are age, sex,
length of hospitalisation, circumstances and causes of death, diagnosis, clinical
data and palliative care means available in Romania.
Conclusions:
There are many specific features of palliative continuing care applied to
inpatients in Geriatric Hospital, but it has the same aim as palliative care
from oncology: to improve the quality of patient's life. These features includes
demographical and clinical data, the symptomatic treatment versus geriatric
syndromes treatment, the load of hard long-term nursing care, supportive
and rehabilitation care related to mental and physical dependence, death
and diagnosis code, economical involvement in satisfying the person's total
needs.
Selected References: i) Infokara 1997/48,4 2) Revue de Geriatrie i998,23(2),i47-i52 3) Infokara 1992/28,5-9 4) Evaluating Palliative Care. Margaret Robbins, Oxford University Press, 1998
13. THE EFFECTS OF REFLEXOLOGY IN THE MANAGEMENT OF CHRONIC PAIN___________________________________________________________ K.S. Roth, Episcopal Church Home, Rochester, NY, United States
Purpose of the Study [in process]:
To evaluate the outcomes of a complimentary therapy (Reflexology) in a palliative
plan of care focusing on management of chronic pain in the elderly.
Description:
Reflexology is a unique method of relaxing, energizing and balancing the
body through the feet. This descriptive correlational pilot study proposes
that a series of 20-minute Reflexology treatments given
three times weekly over a three-month period will show positive benefits in
relation to the phenomenon of chronic pain.
Anticipated Conclusions:
Those residents who participate in this program will return to their optimal
level of functioning and be as pain free as possible. Outcome data
and evaluations will include: Pre- and Post-study i) Geriatric Pain Assessments;
2) Geriatric Depression Screening / Dsvcholocical evaluation: t) Functional
Indeoendence Measures (FIMScores); 4) Physical Therapy / Occupational Therapy
evaluations; and 3) medical hevaluations with
medication / comparisons. Pre- and post-treatment subjective pain
reporting utilizing Visual Analogue Pain Assessment Scales will be documented.
References: Dwight C. Byers (1983). Better Health with Foot Reflexology.
USA, Ingham Publishing, Inc.
~
14. CHAPTER 400 - THE DEATH OF PALLIATIVE CARE IN THE STATE OF FLORIDA
A. Golden, M. A. Silverman, C. Beber, R. Bergman, and B. Roos, University of Miami School of Medicine, Miami Jewish Home and Hospital for the Aged, Stein Gerontological Institute, GRECC/VAMC, Miami, FL, United States
Chapter 400 was passed by the Florida Legislature to protect the rights
of frail elderly nursing home residents. This legislation has led to two major
repercussions for the nursing home. First, Chapter 400 litigation against
nursing homes has become a lucrative industry. It is simple for the plaintiffs
to force a settlement in a Chapter 400related situation by equating the development
of decubiti, falls, and failure to thrive as an abuse of the rights of the
vulnerable destitute nursing home resident. The elderly frail resident is
always championed by the courts. Second, and most important, Chapter 400
legislates against the process of natural death. Those same core concepts
ofgeriatric medicine that have become the cornerstone of the principles of
palliative care. In the last 4 years we have reviewed about ioo Chapter 400
cases for expert testimony. We will present a series of cases where the plaintiff
claims of resident's rights violations contradicts the principles of palliative
care. These cases indicate the crisis facing the application of principles
of palliative care that call for a death with comfort and dignity. Fearing
lawsuits, long-term care facilities are pressuring health-care providers
caring for the nursing home resident to order more diagnostic testing, more
blood tests, more intravenous fluids, etc. The demand is for some type of
artificial intervention to substitute for and therefore prolong the natural
process of death. Chapter 400 in Florida has opened the way for other states
to adopt similar legislation. Unless there arises a national awareness of
the serious ethical dilemma such legislature poses, we could rapidly eliminate
the possibility of evidence-based palliative care. Instead, we will be faced
with the obligation to "Do everything until the very end or else."
15* VALIDATION OF THE QUALITY OF HOSPICE CARE IN NURSING HOMES WITH THE STAS" TOOL__________________________________
E. S. Syring, Saint joseph College, Graduate Nursing Division, Glastonbury, CT, United States
Purpose of the Study:
This prospective correlational study tested the Support Team Assessment Schedule
(STAS®) to seek an internal clinical audit tool for community hospice
programs that quantifies the care they provide to hospice patients who reside
in skilled nursing facilities (SNF).
Description:
Two community hospice programs that care for patients in 12 nursing homes
were chosen and the tool was administered to 27 sets of hospice patient/family,
hospice RN and SNF nurse. The STAS instrument focused on measuring the hospice
teams' perceptions of the patients and families' levels of comfort and coping.
Validation of the teams' STAS testing was performed by simultaneous testing
of the patients, families, the hospice team and the nursing staff of the
nursing homes. The STAS tool demonstrated moderate statistical correlation
with the patient's perception of pain management and the SNF nurse, as well
as moderate correlation between the hospice team and the SNF nurse's pain
management perceptions. When considering the sum of the key domains (pain
and symptom management, patient and family anxiety, communication between
healthcare professionals and patient, communication among healthcare professionals
and spiritual needs), moderate correlation was demonstrated between the SNF
nurse and the patient and family. No STAS statistical correlation was found
between the hospice team scores and the patients and families. The SNF nurses
demonstrated greater correlation in assessing the perceptions of the hospice
patients than the hospice team.
Conclusions:
The audit identified areas of education and collaboration needed to improve
hospice care to the SNF DODulation.
16. INTEGRATING PAIN MANAGEMENT INTO A LARGE HEALTH CARE SYSTEM______________________________________________________
J. Tollett, Patient Care Service, Veterans Health Administration, Washington,
DC, United States
Purpose:
To assure that no patient receiving care in the VHA healthcare system shall
suffer pre- U ventable pain.
L
Description: g A plan to improve palliative care resulted in the development and implementation of a a system-wide comprehensive integrated pain management initiative in the second y largest healthcare organization in the United States. The VHA is in the midst of dra- g matic improvement in pain management including assessment and treatment, evalu- «« ation outcomes and quality, assuring clinician competence and expertise, research ~ and coordination to ensure consistency in all patient-care settings throughout the C system. S
Conclusion: C The VHA experience demonstrates that a very large, complex, multifaceted healthcare I" system will change very rapidly in the presence of a compelling vision, a shared mis- 2 sion and supportive leadership. Y
References: U i) Pain Management Strategy: Multidisciplinary Approach. Veterans Health fl Administration, july, 1998. P
Aamiiiiblrarion, JUiy, 1YYb.
2) Pain Assessment: The 5th Vital Sign®, Veterans Health Administration,
Novembe 1988.
17. DEVELOPING A MODEL OF PALLIATIVE CARE FOR NURSING HOMES
H. Tuch\ N. Strumpf, 'Genesis ElderCare, Kenett Square, PA, United States,
'University of PA School of Nursing, Philadelphia, PA, United States Nursing
homes are currently the site of nearly 20% of annual US deaths. The las months
of life in a nursing home often mean high acute care utilization, uncoordinat
ed care and unnecessary suffering. As part of a national initiative on excellence
ir end-of-life care sponsored by the Robert Woods Johnson Foundation, we
will presen a model of palliative care (PC) being tested in 6 community nursing
homes. W( describe the basic components of PC delivery in this setting:
A detailed program emphasizing pain and symptom management, advance care plan ning and social support. Training in PC principles is directed toward multiple levels o nursing home staff. Approaches are extensively adapted to the unique population culture and regulatory environment of long term care.
i. Development and implementation of a care delivery process, which integrates PC assessments, care planning and interventions into the daily life/work of the homes
2. Delivery of services through designated PC coordinators and specified interdisciplinary teams
3. Ongoing support through a coordinated clinical and operations consultative team
4· Extensive outcome analysis and development of CQl approaches to improve care foi the dying resident.
Details of the model will be presented. The model has the potential to alter the culture of care within the home and can be adapted to most nursing homes. Initial data will be presented. Data collection is ongoing to determine PC goals, effects on pain and symtom management, advance care planning and the use of health care resources.
18. UNDERSTANDING OLDER PATIENTS* VIEWS ABOUT THE END OF LIFE.Vig, N. Davenport, R. Pearlman, University of Washington, Seattle, WA, United States
Introduction:
To provide better patient-centered end-of-life care, providers caring for
older patients need to understand their patients' attitudes about the end
of life.
Objective:
To learn what older patients currently value and to identify their attitudes
and preferences regarding the end of life.
Methods:
We interviewed 16 older patients with non-terminal heart disease or cancer.
The interview consisted of a section of open-ended questions such as: "What
are the most important things in your life right now?" and "What would you
consider a good/bad death?" The interview also contained closed-ended questions
about symptom intensity and the importance of quality of life related items.
Participants voiced their preferences in several end-of-life scenarios. The
open-ended questions were analyzed using content analysis. The data from
the closed-ended questions were analyzed using descriptive statistics, frequencies,
and the Mann Whitney test.
Results:
Participants most frequently identified the following elements as the most
important aspects of their lives: family, health, friends, "being alive,"
financial resources, and pets. Items appearing most frequently in participant
descriptions of bad deaths were pain, prolonged course of dying, accidents,
and dependency. More participants responded that it was "very" or "quite"
important to be given information about their condition than their prognosis.
Questions about end-of-life scenarios elicited a range of responses.
Although the majority of participants identified family as currently "very"
important, less than a third responded that having family present at the
endof-life was "very" important. Family stress and burden were cited
as the reasons for this discrepancy. Those identifying religion as
important wanted religious leaders present when they died. The responses
of the participants with cancer and those with heart disease were not significantly
different.
Conclusion:
Older patients' views of end-of-life care are heterogeneous. Inferences about
preferences for end-of-life care cannot be made from knowledge of patients'
current values. Providers should determine each patient's values and specific
concerns, and incorporate them into treatment plans.