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New Medicare hospice program called too narrow


Some hospice advocates and providers are concerned that too few Medicare beneficiaries will qualify for a CMS experimental program that lets terminally ill patients continue curative treatment after starting hospice care, Modern Healthcare reports.

Medicare patients now must forgo curative services when they enroll in a hospice program to receive palliative care during the dying process. “But studies have found that providing both forms of care concurrently improves quality of life and reduces costs since those patients tend to not make frequent hospital visits,” the publication reports.

Under a demonstration run by the CMS Innovation Center, Medicare is paying some hospices $400 per beneficiary per month for palliative services while also letting providers and suppliers of curative services  bill Medicare.

But“ {u}nfortunately, the early indication from the first group of 71 hospice awardees is that this demonstration has been constructed too narrowly, and that CMS has so tightly managed it that few patients’ are able to participate,” Don Schumacher, CEO of the National Hospice and Palliative Care Organization, told Patrick Conway,  M.D., the CMS’s deputy administrator for innovation and quality. The trade group  comprises not-for-profit hospice and palliative-care programs.

Modern Healthcare reports that patients must meet 14 requirements before they can can be enrolled in the demonstration. The demonstration program is only open to individuals with late-stage cancer, chronic obstructive pulmonary disease, HIV or congestive heart failure who are otherwise hospice-eligible. The most recent Medicare hospice data indicates that only a third of hospice-eligible beneficiaries have one of these diagnoses.

End-of-life cancer care gets more intensive


By Michelle Andrews, for Kaiser Health News


Conversations about end-of-life care are difficult. But even though most people now take some steps to communicate their wishes, many may still receive more intensive care than they would have wished, a study this month found.

The study, published online in JAMA Oncology, examined survey data from the Health and Retirement Study, a national study of U.S. residents older than age 50. Researchers analyzed the responses from the next of kin, usually a spouse or child, of 1,985 participants with cancer who died between 2000 and 2012.

The patients’ family members responded to questions about how frequently patients had signed durable power of attorney documents or living wills or participated in conversations about their end-of life-preferences. Researchers then examined the association between those advance-care-planning activities and the medical care the cancer patients received at the end of life.

Over the study period, the use of durable power of attorney assignment, sometimes called a healthcare proxy, grew from 52 percent to 74 percent among participants. Small declines were reported in other planning activities — from 49 percent to 40 percent for living wills and 68 percent to 60 percent for end-of-life discussions — but they weren’t statistically significant because the levels varied throughout the study period, says Dr. Amol Narang, a radiation oncologist at  the Johns Hopkins University School of Medicine and the lead author of the study.

“Our hypothesis was that we’d see significant increases over the study period in advance directives,” Narang says. “What we saw was that important aspects of advance care planning haven’t increased.”

At the same time, the proportion of patients who were reported to have received “all care possible” at the end of their lives increased substantially over the study period, from 7 percent to 58 percent, even though such intensive treatment may have been counter to their stated wishes.

A durable power of attorney allows consumers to appoint someone to make healthcare decisions for them if patients are unable to do so. Living wills describe the types of medical care people wish to receive (or don’t wish to receive) if they’re incapacitated. Neither requires a lawyer, and forms are often available online.

Simply signing a document isn’t enough, experts say. There’s no substitute for regular communication with friends and family about end-of-life preferences.

“Patients may have signed that power of attorney, but if they haven’t discussed their preferences with that person the proxy may default to ‘all care necessary,’” Narang says. In other words, lacking clear guidance, the healthcare proxy may choose to err on the safe side and approve more care rather than limit or withhold it.

Living wills spell out which treatments someone would want — specifying that they would want to be put on a ventilator, for example, or fed through a tube. But some experts say treatment-focused specificity may not serve patients’ best interests.

Spelling out treatment preferences is only useful in context, says Dr. Diane Meier, director of the Center to Advance Palliative Care.

“Of course you would want to be put on a ventilator if it was going to return you to health,” Meier says.

The more important question is a qualitative one: What is the quality of life that is unacceptable to you? Would you want every measure taken to treat an illness or injury even if it meant enduring extreme pain with little likelihood of improvement? Or would you rather forgo such intensive treatment and be kept comfortable instead? Those are the conversations that need to happen, experts say.

The issue is front and center these days as policy makers debate the recent federal proposal to reimburse physicians for conversations with Medicare patients about advance care planning.

“It’s a significant step in the right direction,” says Jonathan Keyserling, senior vice president for health policy at the National Hospice and Palliative Care Organization.

“Now that healthcare professionals can soon be reimbursed for these intimate and thoughtful conversations, I think we’ll see changes in practice patterns and in decisions by family members.”

Some policy experts say that changing payment practices won’t be enough to change clinical practice.
For physicians, offering treatment, even if there’s little chance it will help, is the only way they may know to show their loyalty and love for a patient, says Meier.

“We have to change the training or nothing will change,” she says.

For that reason, she hopes that the Centers for Medicare and Medicaid Services will require doctors to get some training in how to introduce and take part in conversations about advance care planning rather than simply check a box on a form that says a conversation took place.


Jenny Gold: Study: Suffering increases for dying Americans


By JENNY GOLD | @JennyAGold

For Kaiser Health News
It’s been more than 15 years since the Institute of Medicine released its seminal 1997 report detailing the suffering many Americans experience at the end of life and offering sweeping recommendations on how to improve care.

So has dying in America gotten any less painful?

Despite efforts to build hospice and palliative care programs across the country, the answer seems to be a resounding no. The number of Americans experiencing pain in the last year of life actually increased by nearly 12 percent between 1998 and 2010, according to a study released Monday in the Annals of Internal Medicine. In addition, depression in the last year of life increased by more than 26 percent.

That’s the case even though guidelines and quality measures for end-of-life care were developed, the number of palliative care programs rose and hospice use doubled between 2000 and 2009.

“We’ve put a lot of work into this and it’s not yielding what we thought it should be yielding. So what do we do now?” asked study author Dr. Joanne Lynn, who directs the Center for Elder Care and Advanced Illness at the Altarum Institute.
The study looked at 7,204 patients who died while enrolled in the national Health and Retirement study, a survey of Americans over age 50. After each participant’s death, a family member was asked questions about the person’s end-of-life experience, including whether the person suffered pain, depression or periodic confusion. Those three symptoms were all found to have become more prevalent over the 10-year analysis.

One reason, Lynn said, is that doctors are using a greater range of high-tech treatments, which can lengthen the process of dying without curing the patient. “We throw more medical treatment at patients who are on their way to dying, which keeps them in a difficult situation for much, much longer,” she said. “We’ve increased the number of people put on ventilators and kept in hospitals, and we simply have more treatments that are possible to offer.”

The majority of our research, she added, focuses on wiping out diseases, rather than long-term supports or symptom management for people with chronic conditions or disabilities associated with aging: “Think about how much we invest in curing Alzheimer’s disease, and how little we put into making the course of Alzheimer’s better.”

Most physicians tend to under-treat pain and other symptoms at the end of life because they don’t recognize them or are hesitant to talk candidly about the process of dying and the pain associated with it, said Dr. Tim Ihrig, a palliative care physician at UnityPoint Health in Fort Dodge, Iowa.

“A lot of practitioners aren’t honest. We fail to empower patients with the truth,” said Ihrig. “In that setting, it’s easier to continue to do procedures and diagnostics rather than having that conversation, which is very honest and very difficult.”

Take a cancer patient who has stopped eating and is writhing in pain, he said. An oncologist might recognize the person is going to die, but rather than telling the patient, he or she begins another round of treatment that causes more pain and suffering.

“We don’t have the vernacular in our society to have the conversation about the end of life. People say, ‘I don’t want to take away someone’s hope.’ But in a metastatic pancreatic cancer, for example, we have to redefine what we mean by hope,” he said, citing one of the most deadly cancers.

Often, those conversations aren’t happening until the last days or hours of life, according to Ihrig.

Jonathan Keyserling, a senior vice president with the National Hospice and Palliative Care Organization, points out that half of all hospice patients receive hospice care for less than 30 days.

“If these patients had been under the care of a hospice or palliative care program [earlier], their pain and symptoms could have been brought under control for a much longer and sustained period of time,” Keyserling said via email.

It’s possible, however, that caregivers interviewed in the study simply reported more suffering, reflecting Americans’ changing awareness of pain and depression over the past decade.

“We’ve raised the expectation of better pain management over the years, which may make [the caregivers interviewed] more likely to report it,” says Rosemary Gibson, author of The Treatment Trap and senior adviser at The Hastings Center, a bioethics think tank based in New York. There are many more Americans diagnosed with depression today than in 1998, she added, “so it’s not surprising that people would report it more.”

Nonetheless, Gibson said, the country has a long way to go in improving care at the end of life. The increase in palliative care and hospice use over the last decade was just ”an oasis in the desert. We did nothing to stop the tsunami of overuse [of aggressive treatments] and doing things to people at the end of life that have no benefit.”

It’s time to pick up the speed of change, said study author Joann Lynn.

“We are all going to pass through this part of our lives, and we have a strong interest in its not being awful. So let’s buckle down and get it right.”

This article was produced by Kaiser Health News with support from The SCAN Foundation.


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