Criteria for enrolling dementia patients in hospice

OBJECTIVE: Because survival time varies greatly, it is difficult for dementia patients to meet a key criterion for eligibility for the Medicare hospice benefit: a 6-month survival time. We have developed criteria for the Medicare hospice benefit that include the characteristics of advanced dementia and related medical complications. The purpose of the study was to determine survival time among dementia patients who met these criteria. Additionally, because the National Hospice Organization (NHO) developed its own guidelines while the study was in progress, we retrospectively examined the application of these guidelines to our sample. DESIGN: Two cohorts of hospice patients were studied longitudinally, each for 2 years. SETTING: Nine Midwestern hospice programs. PARTICIPANTS: Forty-seven patients were enrolled in home hospice and institutional hospice settings. MEASUREMENTS: Survival time consisted of the number of days between enrollment in the hospice program and death or the end of the study. Other measures included Activities of Daily Living, ratings of Appetite, Nourishment, and Mobility, Functional Assessment Staging (FAST), a Medical Complications Checklist, and a care plan concerning the use of medications for acute illness. RESULTS: Our hospice enrollment criteria predicted a median survival time of 4 months and a mean survival time of 6.9 months; 38% of patients survived for more than 6 months. FAST scores and Mobility ratings were significantly related to survival time. However, 41% could not be scored on the FAST as their disease progression was not ordinal. Among patients who could be scored on the FAST and who had reached Stage Seven C, their mean survival time was 3.2 months compared with 18 months among those who could be scored and had not reached this stage and 8.6 months among patients whose disease progression was not ordinal, P < .001. When the palliative care plans were examined, less aggressive care plans resulted in shorter survival times, P < .01. CONCLUSION: Our hospice enrollment criteria identified a group with a median survival time of 4 months and a mean survival time of 6.9 months. Using NHO criteria relying on the FAST allows the identification of a subgroup with very high mortality and a short time until death. Although the FAST can identify a subgroup of appropriate candidates for hospice, sole reliance on this measure might decrease access to hospice care for many dementia patients.     

Transcranial power mode Doppler duplex sonography of intracranial aneurysms

Recent events have challenged our health system to increase access to and provide high quality care for patients near the end of life. Simultaneously, Medicare is developing review policies to determine eligibility for hospice patients with select noncancer diagnoses. The purpose of this study was to determine whether the proposed policies met one of their chief goals: accurate identification of patients with a less-than-six-months prognosis. Only 35 percent of 104 patients who died within six months of admission to the hospice used for this study, LifePath Hospice, met the Medicare proposed criteria for hospice eligibility. The median and mean survival time of the sample was 14 and 30 days respectively. Based on this review, it is recommended that Medicare alter their proposed review policies and not limit access to hospice eligible patients who desire and are in need of such services.     

Ethics consultation

Hospices in the U.S. were surveyed in 1990 to find out whether service to blacks and Hispanics was affected by admission criteria and hospice service characteristics of hospices located in or near these populations. Hospice characteristics such as reimbursement patterns, staff interventions, and admission criteria were different depending upon the percent of blacks and/or Hispanics in the hospice service area or actually served by the hospice. Care for Hispanics was more dependent on Medicaid and free care than blacks whose care was financed primarily by Medicare and Medicaid. Hospices identified problems in serving Hispanics as language, reimbursement, and severity-of-illness issues. Hospice admission criteria, especially the primary caregiver requirement, were identified as impeding access for blacks. Hispanics were perceived as presenting the most access and service problems and as the most underserved.     

Tumor cell recognition by lymphocytes: is the MHC always essential?

More than a year has passed since the Center to Improve Care of the Dying and the Corcoran Gallery of Art sponsored the symposium entitled: A Good Dying: Shaping Health Care for the Last Months of Life. Using the National Hospice Foundation sponsored exhibition, Hospice: A Photographic Inquiry, as a backdrop, the symposium included presentations on the current state of hospice care as well as the obstacles that limit access to hospice care. This article represents an update on many of the activities of the National Hospice Organization and the greater hospice community as we continue to improve access to quality hospice care.     

Psychologists and hospice: Where we are and where we can be.

Since the early days of the hospice movement, the role of psychologists in hospice care has been discussed. This study is based on questionnaire responses from hospice programs randomly drawn from those who were members of the National Hospice and Palliative Care Organization. The results clearly demonstrate the need for psychology's role in hospice, but there is much to do to clarify and develop this role. Although psychologists have much to offer in the hospice field and end-of-life care in general, this study found that there are not many psychologists actively working in these settings. Suggestions are made for how psychologists can become more involved in the provision of hospice and other end-of-life care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of the high-tech service delivery experiences of hospice and non-hospice home health providers

This study examined the degree to which national samples of hospice and non-hospice home health care agencies (N = 154) present different organizational profiles and grapple with different patient capacity issues when delivering technology-enhanced services to incapacitated elderly. Hospice agencies employ more part-time staff, make more in-home visits, see more high-tech patients, and provide a wider range of high-tech services than non-hospice providers. Factor analysis of index data confirms that hospice staff have more experience (p < .05) addressing the legal/ethical dimensions of care. Specifically, hospices deal with "right to die" issues more often (p < .05), but not with "delegation of authority" and "patient rights" issues. More agencies of both types have policies for handling decisions about life-sustaining treatment than for dealing with patients having questionable decision-making capacity. Needed agency policies for dealing with limited patient decision-making capacity in hospice and non-hospice home care agencies are reviewed.     

Issues in prison hospice: toward a model for the delivery of hospice care in a correctional setting

This paper examines issues in prison hospice care based on the author's nine years experience as a prison hospice worker and trainer and on data gathered by the National Prison Hospice Association (NPHA) from a number of federal and state prison medical facilities with operational or developing hospice programs, including both scatter-bed and hospice unit models, employing inmate hospice volunteers and the services of outside community hospice agencies and volunteers. The paper discusses DNR orders and curative vs. palliative care decisions, pain management, AIDS care, interdisciplinary care teams, staff and volunteer training and supervision, and the need for compassionate early release and community placement programs. The author proposes a set of preliminary guidelines for the delivery of hospice care in the correctional setting.     

An alternative to traditional medical care for the terminally ill: Humanitarian, policy, and political issues in hospice care.

Indicates that hospice services to the terminally ill offer palliative care rather than curative treatment, emphasizing pain control and supportive/psychological services, and introduces a section of articles on hospice matters. Hospice care is of interest to psychologists because it is a service intervention alternative to traditional medical practice. (0 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Sacred Circle: a conceptual framework for spiritual care in hospice

Hospice care has consistently recognized the need to integrate spiritual care into holistic plans of care for dying patients and their families. Designing and implementing spiritual care interventions can be potentially difficult for hospice practitioners who have not had specific training in theology or pastoral care. Matthew Fox, a theologian, has developed a model of spiritual development that utilizes an ecumenical, ethical framework that can be directly applied to the care of hospice patients and families. This model employs a Sacred Circle approach that begins with an emphasis upon the sense of awe and wonder (the Via Positiva), moves into the next cycle by recognizing problems and negative emotions (the Via Negativa), that then flows into the creative solutions to problems (the Via Creativa), which finally transforms the problem into a new level of understanding (the Via Transformativa).     

Metabotropic glutamate receptors and neuronal degenerative disorders

Spirituality plays an integral role in the care of the terminally ill. Hospice philosophy promotes patient/family centred care that is palliative, holistic and interdisciplinary. Historically, spiritual care has been a major component of hospice care that is consistent with these values. Some issues related to the role of spirituality in medicine and hospice care include the difference between spirituality and religion, the patient-physician relationship, provision of spiritual care, and who provides this care. Guidelines for spiritual caregiving include self-knowledge of one's own spiritual needs, authenticity and honesty and respect for the beliefs and practices of the patient and family.     

Severity index scores correlate with survival of AIDS patients

A major concern of hospices treating AIDS patients is survival prognosis. Patients are eligible for government hospice benefits only if they are in the last six months of life, but for AIDS patients who present at different disease stages, it is often difficult to predict survival. We have tested an index of AIDS severity developed by Alemi et al. (1991, Interfaces, 21(3), 105) for its ability to predict survival in hospice-AIDS patients. Using retrospective analysis of medical records, a severity index (SI) score was determined for 26 AIDS patients who were admitted at different disease stages to a South Florida hospice. The length of stay for each patient was also recorded. The patients fell clearly into two groups, those with stays of six months or less and those with stays of more than six months. The mean SI scores of the two groups were .9188 and .7845, respectively. These scores were significantly different at the p = .005 level. In this preliminary study, the severity score correlated well with survival prognosis. Based on these results, it appears that the severity index may have great utility in predicting survival for AIDS patients seeking hospice admission.     

A comparative study of death anxiety in hospice and emergency nurses

This paper describes a preliminary cross-sectional study which aimed to compare levels of death anxiety and coping responses in palliative care and accident and emergency (A & E) nurses. Forty-three nurses (23 from palliative care and 20 from A & E) were recruited from a district general hospital and nearby hospice. Both sites had the same mean annual death rate of 150 patients. Death anxiety was measured by the Death Attitude Profile-Revised Questionnaire and coping responses were elicited by a semi-structured interview. As hypothesized, hospice nurses had lower death anxiety and they were more likely to recall both good and difficult experiences related to patient care. Unlike the hospice nurses, a subgroup (20%) of A & E nurses reported that they were unable to discuss problems with colleagues. The study has implications for the development of institutional support for staff to enable nurses to provide good quality care for dying patients and bereaved people.     

Advances in hospice care

Hospice care developed in part as a reaction to the impersonal and technology-dependent end-of-life care offered by modern medicine. Unique approaches to care that emphasize interdisciplinary team management of troublesome symptoms and the promotion of quality of life as defined by the patient, are finding their way into all aspects of health care. Symptom control measures have expanded to include chemotherapy, radiation therapy, and multimodal therapies. Both the development of a unique knowledge base and advances in research have fostered the integration of hospice and palliative care into mainstream medicine.     

Ethics in hospice care.

Discusses 4 ethical issues that arise in hospice care: (1) What are the ethical responsibilities to the patient, family, and authorities when hospice workers discover that a patient has been given incompetent and shoddy care at a previous institution? (2) Hospices that advertise themselves as offering complete care should be prepared to deal with psychological and legal issues as well as medical ones. (3) The idea of treating the entire person must include responding to the likelihood that the patient and family may raise profound philosophical and religious questions. (4) Hospice staff should periodically examine themselves on a spiritual or philosophical level. (3 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Randomized Trial of Drug Abuse Treatment-Linkage Strategies.

A clinical trial contrasted 2 interventions designed to link opioid-dependent hospital patients to drug abuse treatment. The 126 out-of-treatment participants were randomly assigned to (a) case management, (b) voucher for free methadone maintenance treatment (MMT), (c) case management plus voucher, or (d) usual care. Services were provided for 6 months. MMT enrollment at 3 months was 47% (case management), 89% (voucher), 93% (case management plus voucher), and 11% (usual care); at 6 months enrollment was 48%, 68%, 79%, and 21%, respectively. Case management and vouchers can be valuable in health settings to link substance abusers with medical problems to drug abuse treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Generalizability of clinical studies conducted at tertiary care medical centers: a population-based analysis

The Marshfield Epidemiologic Study Area (MESA), a geographically defined population registry at one of the participating sites in SUPPORT (a multicenter study of the care of seriously ill hospitalized patients) permitted assessment of generalizability in that study. On the basis of age- and sex-specific rates of enrollment of SUPPORT patients in MESA, we estimate that about 400,000 patients per year would fulfill SUPPORT eligibility criteria in the United States. However, an estimated 925,000 patients, particularly the elderly and those with impairments in their activities of daily living (ADLs), have SUPPORT-like illnesses annually, but do not receive the aggressive care required for study enrollment. The absence of patients not interested in aggressive care in tertiary care-based studies is compounded by the overrepresentation of patients referred from distant areas to the tertiary care center. Such patients tended to be older and to have different diseases than patients in MESA. Care should be taken in generalizing results from clinical and epidemiologic studies conducted at tertiary care centers.     

Preexisting dementia in stroke patients. Baseline frequency, associated factors, and outcome

BACKGROUND AND PURPOSE: The link between stroke and degenerative dementia, especially Alzheimer's disease, is closer than expected by chance. Dementia after stroke may be due to the cumulative effect of vascular and degenerative changes. The prevalence of dementia just before stroke onset remains unsettled. The aim of this study was to determine the frequency of preexisting dementia in stroke patients, associated factors, and consequences on outcome. METHODS: We evaluated the cognitive functioning prior to stroke in 202 consecutive patients with ischemic or hemorrhagic stroke by means of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We classified in the dementia group patients with IQCODE scores of 104 or more. Six months after stroke onset, survivors underwent a battery of neuropsychological tests. RESULTS: Thirty-three patients were demented before stroke (16.3%; 95% confidence interval, 11.2 to 21.4). There was no diagnosis of dementia in 32 of these 33 patients. We determined by logistic regression analysis that female sex, family dementia, leukoaraiosis, and cerebral atrophy are independently associated with prestroke dementia. All survivors who had IQCODE scores of 104 or more at the acute stage met criteria for dementia 6 months later. CONCLUSIONS: Our study showed that one sixth of stroke patients have preexisting dementia. Therefore, some patients with so-called "poststroke dementia" probably had unrecognized preexisting dementia.     

Prognostic factors for survival in patients with brain metastases from renal cell carcinoma

BACKGROUND: Patients presenting with brain metastases from renal cell carcinoma portend a poor prognosis, with a reported median survival of 4-6 months. Given their short life expectancy, these patients generally have been excluded from clinical trials that assess the efficacy of medical treatments. However, clinical impression suggests that some patients may achieve long term palliation. METHODS: The clinical features of 68 patients who were treated at the Institut Gustave Roussy for brain metastases from renal cell carcinoma were collected retrospectively. Using univariate and multivariate analyses, a prognostic model based on independent prognostic factors was established. An external data set of 57 patients was used to validate the model. RESULTS: The median survival was 7 months. On univariate analysis survival was related significantly to the following adverse prognostic factors: no initial nephrectomy, left side and temporal location of brain metastases, presence of fever or weight loss, erythrocyte sedimentation rate > 50 mm/h, and time from initial diagnosis to brain metastases < or = 18 months. Multivariate analyses identified the previous variable as well as the presence of other visceral metastases as independent prognostic factors. Forty-four patients (65%) with no or 1 adverse prognostic factor (average risk group) had a median survival of 8 months and a 26% 1-year survival rate. Twenty-four patients (35%) with 2 adverse prognostic factors (poor risk group) had a median survival of 3 months and a 1-year survival rate of 9%. This model proved to be discriminant in an external data set; the median survival of patients assigned to the average risk group was 11 months (46% 1-year survival rate) compared with 4 months (9% 1-year survival rate) for patients assigned to the poor risk group. CONCLUSIONS: Patients presenting with brain metastases from renal cell carcinoma and poor risk prognostic factors are highly unlikely to benefit from medical treatments except symptomatic procedures. Conversely, the enrollment of patients with average risk prognostic factors into clinical trials dealing with chemotherapy or immunotherapy may be considered.