Changes to Medicare Hospice Wage Index Proposed

On Monday, CMS (Centers for Medicare and Medicaid Services) announced proposed changes to the hospice wage index for FY 2009. The proposed rule would phase out the annual adjustment to the wage index over a period of three years. In effect, this may reduce the payments some hospices receive from Medicare depending on where the hospice provides services, according to CMS [CMS-1548-P, p.22]. The hospice wage index was initially developed to reflect differences in area wage levels around the country. HFA does not provide policy analysis, but HFA is studying the analyses that have been provided by other organizations.

• The Medicare Update blog wrote about the new proposed rule. See the display copy here (PDF) or view the Fact Sheet here.
• The National Hospice and Palliative Care Organization (NHPCO) issued a press release detailing its opposition to the proposed rule. The release highlighted the strains hospices are under financially as the cost of gas, supplies, and pharmaceuticals increases. They also point out a recent Duke study which indicates hospice care results in lower Medicare expenditures.

"Patient satisfaction data collected by NHPCO shows the 98.5 percent of families would recommend hospice to others, reflecting the high level of family satisfaction with care. Coupled with the fact that hospice can be cost effective to Medicare, it seems illogical to put rules in place that would cut down on the care hospice providers could offer," Schumacher noted.

The result of this proposed rule would potentially mean less care to patients and family caregivers during the end of life.

"NHPCO and its affiliate, The Alliance for Care at the End of Life, recently supported bipartisan, bicameral letters from 87 Members of Congress sent to Secretary Leavitt in opposition to the proposed rule and subsequent rate cuts to hospice care. The rule release merely marks the beginning of an arduous regulatory process -- one that we will engage in to the very end to ensure that this valuable benefit to the dying is not sacrificed to short-sighted cost cutting whims," concluded Schumacher.

• The Hospice Blog covers how this proposal could affect rates.

The Hospice and Caregiving Blog will continue to post information about changes in CMS policy towards hospice reimbursement.

Using Humor in Caring for the Terminally Ill

From the UK Journal of Clinical Nursing, Canadian researchers spent nearly 300 hours interviewing staff, patients and their families in both palliative care and intensive care units. They report that the use of humor, by patients and their caregivers, plays a vital role in "promoting team relationships and adding a human dimension to the care and support that staff provided . . ."

HFA Profiles: Pamela Gabbay, Program Director of the Mourning Star Center

Today we introduce you to Pamela Gabbay, Program Director of the Mourning Star Center for grieving children, a community service program of the Visiting Nurse Association of the Inland Counties. Like many of you who support those who grieve, Ms. Gabbay feels a true calling and connection to this important work. You can learn more about Ms. Gabbay and others like her by attending HFA's national teleconference broadcast next week. Find a site in your area to view the teleconference.

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Pamela Gabbay

When Pamela Gabbay, Program Director of the Mourning Star Center for grieving children, a community service program of the Visiting Nurse Association of the Inland Counties – Hospice, describes her path to helping children cope with loss, she says she has “one of those stories.” Gabbay’s parents died a few years apart, when she was in her 20s and just starting a family of her own. Through it all, she simply tried to cope, not really knowing anything about the process of grief and loss. “Six weeks after my mom died,” Gabbay remembers, “I was in a deep spiritual place of sadness and despair, but needing hope and guidance. I told myself, ‘If I ever get out of this pain, I will dedicate my life to helping other people through their own pain’.” And from that moment forward, that is exactly what she has done. She went back to school and began to learn as much as she could about counseling those who are grieving. And then came what she calls the “struck-by-lightning moment.”

Through a contact at school, she heard about a children’s grief center, the Mourning Star Center, that was opening in her community. Not only was she struck by the proximity of the center to her home, but even the name held meaning for her. “My mother had always talked fondly about a boat she had worked on—the Morning Star!” Gabbay said. “I signed on as the first volunteer at the center, and on that first day I knew I was home.”

One of the most wonderful and surprising elements of Gabbay’s work is witnessing the level of compassion and support that the children and teenagers offer to each other. She remembers the conversation between two boys, both of whom had 14-year-old brothers who had died, sharing what their families had each done with their brothers’ belongings. “Watching how the teens make new friends, how they lean on each other and show true compassion for one another, is a true gift,” and is an ongoing reminder of the importance of peer support, Gabbay said.

Of course, supporting grieving children takes much more than peer support. Gabbay and the others on staff at Mourning Star provide a wide range of activities and programming, much of it focusing on how to deal with “special days,” like holidays or birthdays. And as kids grow and change, their needs change as well. As Gabbay points out, the transition is “huge for that 8th-grader who is becoming a high-school freshman without Mom around,” and that same student may need renewed support when facing graduation four years later.

The Mourning Star Center runs concurrent parent groups and Gabbay strongly encourages parents to learn as much about what kids may be facing in grief and loss. Parents of grieving children and teens, of course, often worry that their grieving child may not be doing well in school. Gabbay often uses the analogy of an Etch-a-Sketch, the children’s toy that one draws on and then shakes up to erase the picture. “A kid may be drawing a picture, having fun,” she says, and then when a parent dies, it’s as if “someone comes along and shakes it all up, and all of the pictures and information is gone.” These stories, she says, can often be a way to help adults find a better understanding of what kids may be going through.

These examples can also be very useful when educating teachers and school administrators about grief and loss, Gabbay has found. Just as grief may affect adults cognitively, the same can be true for young people. So a grieving teenager may not be grasping algebra concepts cognitively, and at the same time may be asking the question, “Why does algebra matter right now, anyway?” Gabbay is enthusiastic about the “fabulous, caring individuals” in her local school system and has found the schools to be open about setting up grief groups and accessing the resources that her grief center provides. And she has found that the importance of this not only helps children cope, but that young people will remember those teachers who reacted to their loss in a supportive and helpful way.

When Gabbay speaks to teachers or other adults who want to help children and adolescents cope with loss, one point she always makes is that young people experiencing loss often feel “invisible;” that they feel they are not seen or heard in the same way. Yet she also finds that, while younger children need to be “seen and heard,” teens may prefer that others do not directly address their loss. Gabbay’s advice is to always ask the young person what he or she feels would be most helpful.

One experience that Gabbay has found particularly “amazing—one of the best weekends of my life,” was when she directed Camp Erin, an overnight grief camp funded by the Moyer Foundation. Forty-six kids attended the two –day camp in the mountains, as well as 50 volunteers—“all of whom expressed enthusiasm and interest in attending next year’s summer session the day we ended!” Gabbay recounts. Gabbay describes the arc that she witnessed in the kids who attended. “When they arrived on Friday, they were somewhat trepidatious—they were getting to know each other, asking questions. By mid-day Saturday you could already see a change—they weren’t just bonding with each other, but were actively working on processing their individual grief experiences. You could see a real awareness of the concept that they weren’t ‘alone’—the realization that others understood. For many, it literally added a spring in their step!” By Saturday night’s ceremony, in which each child lit a luminary for the person who had died and placed it in a boat which was then set afloat on the lake, Gabbay said that the adults could see that, “it was as though a burden had been lifted, if even just for that one night.” Many parents made similar observations when reunited with their children on Sunday. Gabbay already has plans to expand participation in this summer’s camp, and the kids at Mourning Star are still talking about it as well.

While Gabbay clearly has found her calling in her work of helping young people cope with loss, she is quick to acknowledge that the work can be difficult. She feels fortunate to work with a strong team at the Mourning Star Center, a team that can “lean on each other in a meaningful way.” She emphasizes how important it is that they can stop for a hug or to talk, recognizing that “it’s okay to be honest and real about how hard it can be to hear these stories every day.” Gabbay also began an ADEC (Association for Death Education and Counseling) chapter in her area. She did this partly out of the need to have a forum for local professionals to network and share ideas, she says, but also because of the need to be with others who, even with “just a look,” can offer understanding and support.

Gabbay recognizes the importance of self-care. A self-professed “huge music fan,” she is sure to attend at least ten concerts every year, and even books passage on a rock-and-roll cruise. One of her favorite activities each week is to “turn up the music, hop into the pool” with her two teenagers, and just “act silly.” These moments help sustain Gabbay, someone who truly feels that “once you find your calling, you can’t stop!

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Pamela Gabbay, M.A., FT, was awarded the Fellow in Thanatology by the Association for Death Education and Counseling and is a Certified Bereavement Counselor. She earned her B.A. in Psychology from California State University, San Bernardino and her M.A. in Psychology from Claremont Graduate University. Pamela is the Program Director of The Mourning Star Center for grieving children in Palm Desert, California. The Mourning Star Center is a community service program of The Visiting Nurse Association of the Inland Counties - Hospice.

Pamela is the Camp Coordinator for Camp Erin - Palm Springs, the first Camp Erin in California. This camp is a free camp for grieving children created in partnership with The Mourning Star Center and The Moyer Foundation. Pamela is also President of the California Chapter of the Association for Death Education and Counseling (ADEC So Cal). ADEC So Cal is an organization dedicated to promoting excellence in death education. Additionally, Pamela is co-owner of Grief Posters.com, a poster company that produces sensitive and educational grief-related posters.

Huge Variations in Cost of End-of-Life Care Across the United States

The Dartmouth Institute for Health Policy & Clinical Practice published its annual Atlas of Health Care. The entire report and executive summary is available for download from their website. The 2008 edition examines how care for Medicare beneficiaries with serious chronic illnesses varies across U.S. states, regions, and hospitals, in the patient's last two years of life. It includes data through 2005 as well as all sectors of care covered by Medicare: inpatient hospital care, outpatient services, nursing, home health care and hospice services.

The Dartmouth study found wide variations in the the amount and cost of care that Medicare patients receive in their last two years. While the national average was $46,412, the cost of care among the top five ranked teaching hospitals (by U.S. News & World Report) ranged from a high of $93,842 at U.C.L.A.'s Medical Center to $53,432 at the Mayo Clinic's St. Mary's Hospital in Rochester. The executive summary explains that these variations in spending are mostly due to the differences in "supply-sensitive care." Put simply, in areas where there are more hospital beds and more physicians available per capita, there will be higher admission rates and more physician visits. Nearly 55% of total spending takes place in acute care hospital settings. The authors report that over the past decade, more and more research shows that higher spending and higher use care does not equate to better care.

The study also addressed the belief that expanding access to non-acute care sectors (skilled nursing or rehabilitation facilities, home health services, or hospices) would save money. They found this not to be the case except for a small decrease in overall for those using hospice care. (A study by Duke University in November 2007 found Medicare savings for hospice vs. non-hospice users, while also giving patients a greater quality of life.) The executive summary states that currently, the United States has invested in certain types of care with the "assumption that more intensive management of the chronically ill results in better health outcomes and greater patient satisfaction. That assumption is being challenged by emerging clinical strategies designed to improve care: the hospice and palliative care movements, the growing chronic disease management industry, and population-based chronic care models that emphasize continuous and coordinated management of patients over time and among sectors of care."

Other articles covering the report:
The New York Times
The Wall Street Journal (requires subscription)
WSJ's Health Blog
AP state-by-state breakdown
The Salt Lake Tribune (examines differences between hospitals within Utah)

Future Lawyers and Doctors Learn about End-of-Life Issues Together

In California, students from the McGeorge School of Law and UC Davis' medical school met for two class sessions on dealing with the rights of the terminally ill. As reported by the Sacramento Bee, 40 law students and 90 medical students participated in the classes.

"There's room for improved understanding between doctors and lawyers generally," said (Ned)Spurgeon, who teaches health law and elder law and policy at McGeorge. ". . . Hopefully, this will mean better-educated doctors and lawyers with respect to enabling patients to have their surrogates make better decisions."

The discussions that arose show that the students do have a lot to discuss. Some pondered whether patients anxiety could be lessened by not using direct terminology like the word "death" and others questioned a mock patient's competency when she expressed a desire not to receive certain treatments. A key goal was to learn how to help patients make end-of-life decisions, and decide who will act as their surrogate when they no longer can do it themselves.

British Study Urges Caution in Antipsychotic Drug Use for Dementia Patients

A study appearing in PLoS Medicine from British researchers at King's College Hospital in London, shows little or no benefit to the use of antipsychotic drugs in patients with dementia. The study examined 165 patients already on the medications and divided them in to two groups, one which continued treatment and another that received a placebo. Most patients who received the placebo had "no overall detrimental effect on functional and cognitive status."

Last December, the Wall Street Journal published two articles about antipsychotic drug use in dementia patients. One article looked at the abuse of the drugs for patients residing in nursing homes. The second article examined efforts by those facilities to wean patients off the drugs and offer other alternatives to control their symptoms.

Missing the Chance to Talk Openly with Dying Patients

In this essay appearing in the Journal of Clinical Oncology, Dr. Bruce H. Campbell discusses his anxiety and apprehension discussing the conditions his terminally ill patient might encounter at the time of death. Although his patient, suffering from thyroid cancer, asks questions about how he will die, Dr. Campbell finds it difficult to directly address his concerns and is frustrated that he does not know how to handle the situation. An accompanying commentary by Drs. Timothy J. Moynihan, Charles F. von Gunten, addresses the missed opportunity Dr. Campbell had to reassure his patient. They explain how they would have handled the interaction:

We both wanted to be standing next to Dr Campbell in this scenario,to help with some possible responses. After the patient asked how he would die, Dr Campbell gently described how patients usually die, yet there was a missed opportunity. One of us might have said, "Tell us what you are most afraid of." Most junior faculty can’t imagine asking something like this, which seems to invite more anxiety and discomfort for both the patient and the doctor. In contrast, it is usually therapeutic because no one can reassure the patient until he knows what is really frightening him.

We expect the patient might have responded, "I don’t want to suffocate to death!" Or, "I don’t want to bleed to death!" "I don’t want my family to witness this." He might also have cried.

We would model being silent in the presence of the patient's distress, which conveys the message that we won’t run away even if the going gets tough. We would reach out, silently, to touch his arm. We would both be seated. When the patient stopped crying we would then say, "Many patients feel just like you do. Fortunately, it doesn’t have to be that way. Would it help to talk about what might happen, and what we’d do so you won’t suffer? Some patients just want to be reassured that the doctor will manage things, but most are reassured by talking about their worst nightmares, and making a plan. How is it for you?"

If the patient wanted, we would discuss aggressive comfort measures, including aggressive sedation if something overwhelming happens. We would firmly tell him he won’t die feeling like he is suffocating. While we can’t control the cancer, we CAN control how he feels. We can also control the environment so his family and the nursing staff won’t be traumatized.

After the interaction, we’d join Dr Campbell in the hall with his colleagues and the nurses, and debrief the interaction in order to meet the team's personal self-care needs. We’d listen while they told us how uncomfortable they felt. We’d tell stories about similar situations when we felt helpless, and how we got to the place where we don’t feel that way anymore. We’d rehearse what to do in the case of worst scenarios, supervise the writing of the orders, and make sure the nurses knew what to do and whom to call . . .

Weinberg Foundation Offering Family and Informal Caregiver Support Grants

The Harry and Jeanette Weinberg Foundation, based in Baltimore, announced a new grants programs aimed at supporting caregivers of the elderly. The Foundation plans to award 12 to 20 grants ranging from $300,000 to $900,000 to nonprofit community groups, who will also need to provide a local match. Non-profit 501(c)(3) organizations, including aging and human service agencies, faith-based and other community-based organizations, tribal organizations, and units of local government are encouraged to apply. For more information, see their website, www.hjweinbergfoundation.org.

Providing Culturally Sensitive Nursing Care

Marilyn Hardy Bougere, MSN, RN, CNS, a nursing instructor at Jacksonville State University in Alabama, provides an article for MinorityNurses.com, addressing how understanding how cultural difference effect a patient experiencing grief, can enhance nursing care. The article itself provides an excellent review of some older literature. Following the article, there are two fictionalized case studies about providing culturally and linguistically competent nursing care. HFA's 2009 Living with Grief teleconference will focus on multiculturalism and end-of-life care.

"As the racial, ethnic and cultural diversity of the U.S. population continues to increase, there is an ever-growing need for the health care profession to become culturally competent in all aspects of care delivery—and this includes the care we provide to grieving patients and their families. A recently published article on cultural diversity and grief states that the need for culturally sensitive grief/bereavement educators and counselors is on the rise and that health care providers must continue to expand their knowledge of the many ways that people grieve."

A Team Approach to Reducing Bedsores in Nursing Homes

Today's New York Times reported on a collaborative program carried out by 52 nursing homes around the country, sponsored by the Centers for Medicare and Medicaid Services. The team effort, involving not only nursing staff, but laundry workers, nutritionists, and maintenance workers, reduced the incidence of severe bedsores (medically known as pressure ulcers) by 69 percent. Experts say two million Americans acquire pressure ulcers each year.

"Dr. Horn, of the Institute for Clinical Outcomes Research, praised the collaborative as 'the first major national effort driven by Medicare to reduce pressure ulcers.' But she said that better outcomes could be achieved if more nursing homes improved their documentation, so that all of the information on a given resident, including details on eating, urinary and bowel function, appeared on a single sheet, with key reminders to nursing assistants and other staff members about best practices.

Institutional change and work-flow redesign are critical, she added, given the high rates of turnover in nursing home staff across the country."

Help for Hospice Angels

Vince Chiles

“You’re such an angel. . . You were sent by God. . . You’re so special, thank you so much.” These are the kinds of comments that hospice nurses, social workers, home health aides, chaplains, and volunteers hear everyday from their patients and patients’ families. Hospice staff have been compared to angels, but unlike their heavenly comparisons are mortal, and as a result are affected by the work they do daily..

Being in close proximity to the terminally ill and dying affects the hospice professional in profound emotional, social, spiritual and psychological ways. It is next to impossible not to form some type of emotional bond to hospice patients, and when they die, the professional and volunteer grieves. The hospice professional and volunteer must temper social interactions with family and friends who aren’t as comfortable talking about death and dying, and might feel as if they, as hospice workers, don’t have people who understand their needs. By working so closely to death, one will naturally question his or her own religious and/or spiritual beliefs, and sometimes wrestle with doubt and uncertainty. As the hospice professional searches for good answers for all the suffering and pain she witnesses, she may also experience psychological stress from this work.

It is important that the seasoned hospice professional develop an arsenal of self-care techniques to combat the potential occupational hazards. I feel the best self-care techniques are those that are natural, effortless and produce instant benefit. By natural I mean that these are skills you already possess. (You may be unaware of their self-care power.) By effortless I mean that these skills require little or no physical effort to perform. Finally, by instant I mean that they only require a few seconds or minutes to perform. Self-care skills that combine these three elements are easy to use and to benefit from. Some examples:

Breathe Deeply: Deep breathing is a great example of a self-care technique that meets the above criteria. Breathing is natural; we all do it, and it is often effortless. When feeling stressed or burdened by the emotional pressures of hospice work, this technique can be used for short periods of time, in a few seconds to minutes, and it produces quick benefits. You perform this exercise by focusing your attention on inhaling and exhaling, and then comfortably allowing each exchange to last three to four seconds. Deep breathing helps to increase oxygen flow to your brain, which allows you to clear your mind and feel refreshed. As a result, deep breathing is a natural, effortless, and instant self-care technique.

Laugh Out Loud: Another easy and fun self-care technique is to laugh longer and harder each time someone tells a joke or a funny story. Laughing has many benefits, from stimulating the immune system to improving one’s mood. Laughing at someone else’s joke improves inter-personal relations, and also helps to promote the other person’s mood. Laughing is natural, it’s simple, and it’s instant. It may feel a little awkward at first, but after you experience its benefits, it will be contagious.

Practice Kindness: We’ve all seen the bumper sticker “Practice Random Acts of Kindness.” Being kind by holding a door open, or by complimenting a store clerk on good service, takes only seconds to do, but kindness can go a long way to promote one’s well-being. We may not think kindness is natural, but it is - our survival depends on it. Kind deeds can be effortless, and the benefits are instant in improving the outlooks of the giver and receiver.

Feel Grateful: Remind yourself to feel grateful everyday. Feel gratitude for the air you breathe, your home, your loved ones, and your life. Gratitude is effortless. It requires only a momentary reflection on what you appreciate in your life. Feeling gratitude is a great self-care technique because it can be done by reflecting on five to 10 things you appreciate today. The rewards of practicing gratitude include a better outlook and increased sense of satisfaction with oneself.

Do you have a self-care technique that you have found especially helpful and easy to do? If so, please share it with us here.

Vince Chiles, MSW

Disturbing Report of Prescription Drug Abuse in Nursing Homes

The Wall Street Journal published an article last week on the use of antipsychotic drugs to subdue patients suffering from Alzheimer's disease and other dementias in nursing homes. The article points out the challenges faced by nursing homes in caring for these patients. A 1987 federal law limits how and when a patient can be physically or chemically restrained. Also, according to the article, the increase in dementia patients have left staff overburdened. The article focuses on New York state and its efforts to examine how antipsychotic drugs are being used in nursing homes there.

California Fire Update: HFA Responds with Donation

(Nov. 1) – In response to financial needs of hospice patients and families affected by recent wildfires in Southern California, Hospice Foundation of America will donate $5000 to the California Hospice Families Relief Fund to help hospice families with extraordinary expenses incurred as a result of the fires.

The California Hospice Families Relief Fund, managed by the California Hospice Foundation (CHF), is a restricted fund created to ease the financial burden of hospice patients and families whose homes were in the path of the fires. Unanticipated expenses for the families include medical transportation to relocate patients living in evacuated or burned areas, special professional cleaning to remove fire residue from homes of patients with compromised respiratory systems, and lost wages for family caregivers who helped to evacuate or stayed at the bedside of their loved ones during the crisis.

“These families are in the midst of one of the most emotionally difficult periods possible – the impending loss of a mother, father, spouse or other family member. In the aftermath of the fire, they are urgently trying to restore a sense of normalcy for their loved one’s comfort. They were already facing special expenses but now face new financial pressure,” said Laura Miller, past chair of the California Hospice Foundation and president and CEO of The Elizabeth Hospice, which serves some of the hardest hit areas in North San Diego County,

Individuals may send tax deductible donations to:

California Hospice Families Relief Fund
c/o California Hospice Foundation
3841 North Freeway Blvd.
Suite 225
Sacramento, CA 95834

One hundred percent of the donations made to the relief fund will go to affected families. Administrative costs are being covered by CHF. A three-person panel will review applications for financial assistance and distribute funds appropriately.

For more information on the California Hospice Families Relief Fund, call 888-252-1010, or visit the California Hospice Foundation’s website, www.hospicefoundation.info. The California Hospice Foundation is a registered 501(c)(3) charity.

Two Leaders in Pain Management and EOL Care Receive Awards

On October 24, Kathleen M. Foley, MD, of Memorial Sloan-Kettering Cancer Center in New York City, and Perry Fine, MD, of the University of Utah School of Medicine, received the Josefina Magno Excellence in Education and Leadership Award for 2007 at the 9th Annual Josefina Magno Conference on Palliative Care. The award recognizes contributors to the science of pain and symptom management. The award and professional conference are named for the physician credited with pioneering the modern concept of hospice and palliative care in the United States in the 1970s. It is sponsored by Capital Hospice, which was founded by Dr. Josefina Magno as Hospice of Northern Virginia in 1977.

Dr. Foley spoke with the Hospice Foundation of America about her work at Memorial Sloan-Kettering and the changes that she has seen in pain management at the end of life.

The Controversy Over Medical Futility Laws in Texas

The New England Journal of Medicine July 2007 issue included an article by Robert D. Truog, M.D., addressing the ethics behind the Texas Advance Directives Act. This act allows hospitals to withdraw life support if an ethics committee has determined that life support is medically inappropriate, as long as the hospital gives 10-day notice to the family and attempts to find an alternate provider. The article addresses some of the ethical considerations that go into making such a determination. An October 11, 2007 Letter to the Editor in the Journal by Robert L. Fine, M.D., a physician and clinical ethicist who was involved in the development and use of the Act, attempts to refine some of Truog arguments and argues for the support the Texas act, stating that, ". . .the Texas process remains the best approach when family requests conflict with professional obligations at the end of life."

When is Medication Appropriate for Grief? Dr. Kenneth Doka Shares his Thoughts

Dr. Kenneth J. Doka

A New York Times blog entry dated October 10 ("For Some Bereaved, Pain Pills Without End") reports that Columbia University researchers are studying anti-anxiety prescription drug use by the elderly. Although not specifically looking for trends in the treatment of bereavement, researchers inadvertently discovered that over half of the 33 Philadelphia-area doctors included in the study indicated they had prescribed potentially addictive anti-anxiety drugs specifically for bereavement. In addition, researchers interviewed 50 elderly long-term users of the drugs. Twenty percent said they were prescribed these drugs for bereavement, but then never ceased using the drugs, resulting in an average use of nine years.

As a professor of gerontology, certified thanatologist, certified counselor and minister, I am often asked if people who are grieving should receive medication for their grief.

My answer is never black and white, because the alternatives are really more nuanced. Whether grief or some other condition, it is medically irresponsible to prescribe any drug – antibiotics, pain relievers, psychotropic drugs -- without doing a full assessment of a patient and the situation. Medications should be used when grief is highly disabling, that is, when that patient (after the initial period of mourning) is not sleeping, eating, or able to function in his or her normal role, such as caring for children or going to work. And, if medication is prescribed, it should always be prescribed along with therapy, but never instead of therapy.

In the case of grief, the assessment should not be based on the nature of one’s loss but how the person is coping with a loss. If the measure of need is based on the nature of loss, why not give funeral directors the ability to write prescriptions?

Ken Doka, PhD, MDiv, is a senior consultant to HFA and a professor of gerontology at the College of New Rochelle in New York.

Tension Exists Between Physicians and Patients, Particularly at the End of Life

This Boston Globe article addresses the tensions that can develop between physicians, their patients, and their patients' families. These conflicts can be especially daunting when treating a patient with a serious illness or at the end-of-life. The article points to a growing conflict as the nature of the doctor-patient relationship evolves.

Samira K. Beckwith, LCSW, CHE, looks at these conflicts (PDF), as well as familial disagreements in general, for HFA's book, Living With Grief: Ethical Dilemmas and End-of-Life Care. She also discusses the role of hospice in resolving these conflicts.

A Family Practice Physician in Maine Discusses the Emotional Impact of Caring for Patients at the End-of-Life

An October 3, 2007 article in The Lincoln County News examines the impact of providing end-of-life care on physicians. Dr. Chip Teel, discusses how he and his patients navigate this phase of life. Teel states, “It is an enormous privilege to be a part of someone’s end of life."

The Mental Health Effects of Caregiving

A blog post on MSCaregiver.com questions the idea that caring for those with a serious impairment, in this case multiple sclerosis, impacts caregivers' mental health more negatively than the other stressors of life. In fact, the blog asserts that caregivers mental health is not worse than the general population.

Caregivers do need to pay attention to their overall health and seek assistance when needed. View some tools for caregivers, including a caregiver self-assessment questionnaire, at HFA's Caregiver's Corner.

Spirituality in Medical Curriculum

Along with memorizing body parts and learning to diagnose and treat diseases, students in the School of Medicine and Biomedical Sciences are being introduced this fall to a new set of courses incorporating spirituality into their training to become physicians. Fourth year students can select a popular elective, "Faith, Medicine, and End-of-Life Care."

Clergy and faith leaders can also enhance their understanding of issues related to end-of- life care. Hospice College of America offers an online course developed by the Hospice Foundation of America in cooperation with the Florida Department of Elder Affairs and The Center on Aging at Florida International University. Engaging Faith Communities in End-Of-Life Care.

The Words We Use to Describe Caregiving

Sharon K. Brothers, MSW, blogs on the "Caregiver's Language of Caring" and how words reflect a caregiver's feelings about the people they care for. Her blog, Caregiving at the Crossroads, offers a personal look at caregiving training.

HFA's Caregiver's Corner offers tools and support for caregivers at each step of the caregiving journey.

Posted September 4, 2007

The Physician's Role at the End-Of-Life

American Medical News published an article about the physician role in offering comfort to a terminally ill patient. The article discusses a variety of studies that have shown that greater communication by physician can help patients dealing with a terminal illness and help families through bereavement. Doctors who remain more distant can leave families feeling abandoned.

Learn more about the role of caregivers in preparing for the end-of-life from HFA's 2007 Teleconference, Living With Grief: Before and After the Death.

Published September 3, 2007