MNHPC ALERT - files.ctctcdn.comfiles.ctctcdn.com/5d6ab4a7201/83339c2f-70bf-4319-b... · MNHPC is...

MNHPC is grateful to be celebrating 35 years of being a trusted leader amp advocate in hospice amp palliative care

IN THE NEWS

EDUCATIONAL OPPORTUNITIES

UPCOMING WEBINARS

CYCLICAL ITEMS

HIGHLIGHTS

MNHPC ALERT September 30 2015 Monthly eNewsletter

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1 | Register Now Fall Forum

1 | We Honor Veterans Meeting

2 | Call for Proposals - Open

2 | World Hospice and Palliative Care Day

3 | We Honor Veterans Article

4 | An Aging Population

4 | A Nurse with Fatal Breast Cancer

5 | MCDES Fall Conference

6 | Minding Our Elders

7 | Volunteer Manager Series

7 | Hospice FY2016 Final Payment Rule

8 | NGS J6 Webinars

9 | Hospice News Network (HNN)

21 | Calendar of Events

22 | Job Opportunities

22 | Member Benefits

Register Now MNHPC Fall ForumAddressing Ethical Issues at the End of Life

Fall Forum SpeakersChuck Ceronsky MA Director of Spiritual Health Services at UM Health Ethics Lead for Fairview Health Services

Thaddeus Pope JD PhD Director of the Health Law Institute Associate Professor of Law at Hamline University

Vic Sandler MD Medical Director of Fairview Hospice Co-Chairman of the Ethics Committee of University of Minnesota Medical Center

Click here to register for the Fall Forum on November 12 2015

We Honor Veterans MeetingNovember 19th | First Lutheran Church 900 Bemidji Ave N Bemidji MN 56601Registration will open on October 5th

Hosting this EventEssentia Health - St Maryrsquos Hospice East Range TeamCHI Health at Home - Breckenridge and Little FallsHorizon Health Services - HospiceHospice of the Red River ValleySanford Bemidji Hospice

This forum will explore ethical challenges that members of hospice and palliative care teams commonly face when caring for patients and their families near the end of life


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World Hospice and Palliative Care Day is a unified day of action to celebrate and support hospice and palliative care around the world

This yearrsquos theme for World Hospice and Palliative Care Day is ldquoHidden Lives Hidden Patientsrdquo This yearrsquos theme will focus on the patients living in unique conditions that often struggle with access to palliative care including children LGBT individuals HIV prisoners soldiers and those living in rural settings

Aims of World Hospice and Palliative Care Day

bull To share our vision to increase the availability of hospice and palliative care throughout the world by creating opportunities to speak out about the issues

bull To raise awareness and understanding of the needs ndash medical social practical spiritual ndash of people living with a life limiting illness and their families

bull To raise funds to support and develop hospice and palliative care services around the world

2016 MNHPC Annual ConferenceCall for Proposals is Now Open

Visit the MNHPC website for full details on the conference and proposal guidelines

On MNHPCrsquos website you will findbull Important dates and deadlinesbull The goal of the 2016 conferencebull The conferencersquos target audiencebull 2016 Areas of Emphasisbull Types of Presentationsbull Levels of Presentationsbull Instructions on submitting your proposal


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IN THE NEWS We Honor Veterans

The Metro Area Hospice Volunteer Coordinators Group (MAHVCG) started approximately 20 years ago as a way of pooling limited financial resources allowing participants to offer training sessions that would not be possible any other way This group has 20 members from 13 different hospice organizations working together on producing and training dynamic volunteers Over the years this group has transformed into a collaborative team that shares experience knowledge support and learning opportunities Out of this group we are trying something new developing and implementing an entire volunteer program as a team

Five years ago the Veteranrsquos Administration and the National Hospice and Palliative Care Organization came together and formed a program called We Honor Veterans This program was begun to address the unique needs of our veteran population during their hospice experience ldquo1 out of every 4 dying Americans is a Veteranrdquo This is done through staff development community education and recognition of the sacrifice that each veteran made when agreeing to put their life on the line for the protection of our country

The hard fact is that it has been difficult to find veterans who are willing to volunteer their time with a hospice Itrsquos even harder to find a veteran that is willing to sit with another veteran during this time We can speculate why but the reality is that there are 124 licensed hospice providers in the State of Minnesota 28 are located within the seven counties that create the Twin Cities and we are all vying for the same volunteers We had each tried marketing in some form prior to the forming a subgroup of the MAHVCG to pool our resources knowledge and experience and try something newhellipdeveloping a program together

Fairview HealthPartners Our Lady of Peace and St Croix hospices decided to work in collaboration on developing a unique version of We Honor Veterans Like every good idea we started with more questions than answers We have worked through most of them and offered our first training in June 2015 Many lessons were learned from both our marketing and ownership of volunteers we have made changes and will now be offering our second training this October

Lessons learned working as a group offers more richness than trying to ldquogo it alonerdquo We all bring different skills and experience to the table and we learned a lot from each other By pooling our resources we were able to afford more than we could have alone in terms of technology outreach and expertise While we marketed our first training to more than 50000 people we had five new volunteers attend training We know the need is great and that this initial response does not adequately reflect the interest It has taught us we need to be more targeted in our advertising Based on the astonishing response from patients families and the general public it is clearly a program of value

This article was created as a collaborative effort between Fairview HealthPartners Our Lady of Peace and St Croix Hospice for the We Honor Veterans Program

The article was written by Kelly Pietrzak at Our Lady of Peace Hospice


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IN THE NEWS

An Aging Population Without the Doctors to MatchBy Marcy Cottrell Houle | September 22 2015

An aging generation must confront its growing need for health care with the looming shortage of geriatric specialists Op-ed writer Marcy Cottrell Houle writes ldquoWith a shrinking number of geriatric specialists who will care for us as we agerdquo

As the US population quickly ages and less and less students enter the field of geriatrics the nation is facing a shortage of geriatricians to meet the needs of the growing number of seniors Cottrell Houle reveals many frightening statistics in this article ldquoThe nationrsquos fastest-growing age group is over 65 Government projections hold that in 2050 there will be 90 million Americans 65 and older and 19 million people over age 85 The American Geriatrics Society argues that ideally the United States should have one geriatrician for every 700 people 65 and older But with the looming shortage of geriatricians the society projects that by 2030 there will be only one geriatrician for every 4484 people 75 and olderrdquo (The New York Times 922)

Amy Berman Nurse and Senior Program Officer

with the John A Hartford Foundation

A nurse with fatal breast cancer says end-of-life discussions saved her lifeBy Amy Berman | September 28 2015

Nurse expert in care of the aged and senior program officer at the John A Hartford Foundation Amy Berman discusses the life-altering impact of end-of-life conversations with physicians Berman was diagnosed with stage 4 breast cancer nearly five years ago and since has worked with a palliative care team to pick the course of treatment that best aligns with her wishes and desired lifestyle

Berman describes the way in which these coversations about her end-of-life care treatments have been ldquolifesavingrdquo Berman says ldquoThis kind of conversation initially helped my care team understand what was important to me and helped clarify my goals of care Faced with an incurable disease and a prognosis where only 11 to 20 percent survive to five years and there is no statistic for 10-year survival because it so rarely happens I came to understand that my priority was to seek a ldquoNiagara Falls trajectoryrdquo mdash to feel as well as possible for as long as possible until I quickly go over the precipice Quality of life is more important to me than quantity of days if they are miserable daysldquo (The Washington Post 928)

Marcy Cottrell Houle Co-author with Dr Elizabeth Eckstrom of ldquoThe Gift of Caring Saving Our Parents from the Perils of Modern Healthcarerdquo


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Minnesota Coalition for Death Education and Support

MCDES Fall ConferenceWhen Death Enters The Intersection of the Personal and Professional in Work with the Dying and Those Living with Life-Limiting Illness

Friday October 2 2015 830 am - 430 pm DoubleTree by Hilton Hotel Minneapolis North 2200 Freeway Blvd Minneapolis MN 55430

This collaborative workshop will set forth a clinical understanding of the often unconscious forces (countertransference) that can create positive and negative outcomes at the profound interface of life and death The premise of the workshop is that if we have the courage to confront the totality of our emotional behavioral and professional responses if we can allow ourselves our foibles vulnerabilities and mistakes we can use our countertransference responses to inform and enrich our work

FeaturingRenee S Katz PhD FT is a Licensed Psychologist Board Certified Diplomate in Clinical Social Work and Fellow in Thanatology

Sessionsbull TheldquoCrdquoWordinClinicalandEthicalPractice Introduction to

Countertransference Current Definitions Potentiates of Countertransference Role in Ethical and Culturally Informed Practice

bull WorkingwithDyingTheHeartofHealing What the Dying Want Pain Suffering and the ldquoGood Deathrdquo Responding to Desire to Die Requests Options in Living and Dying

bull Personal-Professional-EthicalIntersections Common Countertransference Themes Countertransference Defenses and Enactments Unique Practices in Work with the Critically Ill and Dying

bull AddressingCountertransferenceSkillsandStrategies Personal-Professional-Organizational Vulnerabilities Techniques and Tools Relentless ldquoSelf-Carerdquo

Registration after Sept 25 2015Current MCDES Members $135 | StudentsAdults over 55 $115 Non-MCDES Members $170 | StudentAdults over 55 $145

Full details and registration information httpbitly1EBsPdU

Meet the PresenterRenee S Katz PhD FT

A clinician author and trainer she

has worked with the dying bereaved

and those living with serious illness

for over thirty years


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Horizon Health Services

Minding Our EldersThursday October 8 2015 830 - 1000 am (Session 1) 1130 am - 130 pm (Session 2) or 300 - 500 pm (Session 3) Horizon Center 26814 143rd St Pierz MN 56364

Carol Bradley-Bursack author of Minding Our Elders will be the Keynote Speaker at Horizon Center She will take you on a journey into the life of a caregiver while sharing her experiences and her heartwarming stories Carol works as a consultant on aging and caregiving issues Her elder care newspaper column ldquoMinding Our Eldersrdquo runs weekly in print and on-line

FeaturingCarol Bradley-Bursack is the author of ldquoMinding Our Eldersrdquo and works as a consultant on aging and caregiving issues

RegistrationSession 1 (830-1000 am) | $1500 (Includes Autographed Book)

Session 2 (1130 am-130 pm) | $2000 (Includes Lunch amp Autographed Book)

Session 3 (300-500 pm) | $1500 (Includes Autographed Book)

Full details and registration information httpbitly1P1uls0

Meet the PresenterCarol Bradley-Bursack

Author of ldquoMinding Our Eldersrdquo

consultant on aging and caregiving

issues and elder care newspaper

columnist


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UPCOMING WEBINARS

Never miss another webinarDid you know that you can access any webinar offered by MNHPC any time We archive each webinar to allow memebers to access them online at their convenience For a full list of webinars visit our fully archived list at httpbitly1sjkdNd

Thursday October 1st 2015 | 200ndash330 pm CT

Volunteer Manager Series Ethics amp Leadership Raising the Bar for Hospice VolunteerismIt is common for volunteer managers to ask the question ldquoHow do we get people to value volunteer programsrdquo The answer is simple show the value You may think ldquoBut I see the value of what volunteers accomplish on a daily basis rdquo Yoursquore right but the problem is that other people may not see it What needs to change Volunteer programs need to go above and beyond meeting the 5 minimum and volunteer managers need to become leaders This webinar will focus on some of the obstacles such as working with challenging situations and ethical dilemmas It will also address ways volunteer managers can increase leadership strategies within their departments ndash organizationally and even nationally

Register online httpbitly1MB0zYT

Thursday October 8th 2015 | 200-330 pm

Hospice FY2016 Final Payment Rule amp HQRP UpdateIn an era of tightening oversight hospices are dealing with the most significant payment change since the inception of the Medicare hospice benefit This webinar will review and discuss the FY2016 hospice final payment rule It will provide a comprehensive update of CMSrsquos plans and timelines for implementing hospice payment system reform and changes related to the inpatient and aggregate caps the Hospice Quality Reporting Program (HQRP) and diagnosis claim coding Join us to learn more about the new payment structure and policy changes

Register online httpbitly1KKdHaf

Webinars presented by

Meet the PresenterGary Gardia MEd MSW LCSW CTGary Gardia Inc wwwgarygardiacom

Meet the PresenterKatie Wehri CHC CHPC

Wehri amp Associates LLC


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UPCOMING NGS WEBINARS

Wednesday October 7th 2015 | 200ndash300 pm CT

J6 Letrsquos Chat Website WednesdayClick here for full details httpbitly1JDgX6l


J6 Letrsquos Chat Website WednesdayClick here for full details httpbitly1FFkuq2

Wednesday October 21st 2015 | 200ndash300 pm CT

J6 Letrsquos Chat Website WednesdayClick here for full details httpbitly1O2DorY


Wednesday October 21 2015On the Road with NGS Medicare Minneapolis Airport Marriott 2020 American Blvd E Minneapolis MN 55425We urge you to send someone from your hospice to this meeting because it is going to provide everyone with an opportunity to ask the NGS representatives about the new regulatory changes and all of the changes that have already taken place This is our Medicare Administrative Contractor so letrsquos fill the room with hospice providers

Sessions offeredbull MSP Home Health and Hospice Scenariosbull Planning Strategizing and Responding to a Medicare Auditbull HH+H Resourcesbull Home Health Documentation amp the ADRbull HH Certification of the POC amp F2F Encounterbull Hospice Nursing Documentation Meeting terminal prognosis and level of servicebull Hospice Letrsquos Chat Medicare Updates New Regulations for Hospicebull FQHC Cost ReportMA Supplemental Paymentbull FQHC Prospective Payment System

Cost $149 Register online httpbitly1iLBoIG If you are planning to stay at the Marriott use this link to receive discounted room rates httpbitly1VnrYVC


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HOSPICE NEWS NETWORK WEEK OF SEPTEMBER 8 2015

JAMA ARTICLE CALLS FOR ldquoTHE NEXT ERA OF PALLIATIVE CARErdquoTwenty years ago SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment) involved over 4000 patients in a study and determined that there were ldquosubstantial shortcomingsrdquo in end-of-life care The negative out-comes of the study were published in over 1000 peer-reviewed publications The study ldquogalvanized efforts to improve advanced illness carerdquo Following SUPPORT leaders emerged to focus on improving end-of-life care and ldquoalleviating physical and psycho-logical symptoms for patients with complex serious illness and their familiesrdquo

An article in JAMA ldquoThe Next Era of Palliative Carerdquo notes that palliative care emerged and prospered following SUPPORT In spite of this says the article ldquo20 years after SUPPORT little has changed for seriously ill patients who continue to receive poor quality high-cost care without being informed of likely treat-ment outcomes so that they would be able to make decisions that reflect their valuesrdquo While about 75 of patients could benefit from palliative care there are significant workforce shortages inadequate access to palliative care and inconsistent referral patterns and reluctance to utilize palliative care

Now it is time say the researchers of the JAMA study for pal-liative care to ldquoembrace a broader focus on systems of care measurement and accountability for palliative care services and national policy changes that promote universal provision of high-quality advanced illness care Without these changes it will not be possible to achieve the goal of improving the experience of patients with serious illnessrdquo

Embracing a broader healthcare system requires a clearer defini-tion of the role of palliative care specialists while also assuring that ldquononspecialists provide compassionate patient- and family-centered carerdquo Strategies for quality improvement may also be applied to end-of-life care

Measurement and accountability should first and foremost ldquoroutinely measure outcomes that matter to seriously ill patients and their familiesrdquo This will call for tracking of specific actions such as discussion of patient goals and recording the status of resuscitation orders for seriously ill patients Additionally this information needs to get to individual clinicians and groups of clinicians who are caring for the patient

In terms of national policy changes the authors note that the

recent decision to reimburse physicians for end-of-life care discussions is an important step They call for increase in funding for palliative care research And they say ldquoFederal funding must be aligned with a national goal of improving the experience of seriously ill patients and their loved onesrdquo The article is posted online first and is available as a free article (JAMA 83)

GAWANDErsquoS BOOK ldquoBEING MORTALrdquo IS FOCUS OF ONLINE BOOK STUDYThe Dallas Morning News selected Atul Gawandersquos ldquoBeing Mortal Medicine and What Matters in the Endrdquo for its 2015 annual Points Summer Book Club The paper identified key issues from the book and invited readers to respond via an online blog

On day one the leader of the discussion Nicole Stockdale notes the difficulty most of us have in facing our own mortality On day one readers were invited to write on the blog in response to two questions ldquoWhat personal fears do you have about aging Did reading this book change those feelingsrdquo

On day two Stockdale highlights Gawandersquos claim that venera-tion of elders has changed in our culture deferring instead to veneration of youth and independence As we age we must at some point begin to give up some of this independence The focus of the blog on day two asked readers to respond to two questions How do we handle individually and collectively the shift from independence toward dependence ldquoHow can we do a better job meeting expectations for senior livingrdquo

Day three focuses on our healthcare system saying that it ldquohas a tendency to address questions of mortality with medical solu-tions more pills more surgeriesrdquo Gawande has strong feelings that the ldquotreatment-at-all-costs modelrdquo is not the best solution For readers to consider and respond on the blog was this ques-tion ldquoWhat are the most important fixes the system needsrdquo

Day four addresses Gawandersquos major theme that encourages all of us to ask what wersquoll be living for when we are old ill or frail enough to depend on others for care Stockdale says that many who are blogging are already at this stage of life The blog ques-tions for this day are ldquoWhat makes life worth living How do you keep it worth living in old agerdquo

Stockdale entitles day five ldquoFutile fights death panels and decid-ing when to let gordquo She recalls the case of a young mother who is profiled in Gawandersquos book She also talks about the various decisions patients can make and the ethical dilemmas that must be faced The blogging questions for the day were ldquoWhat should guide these end-of-life decisions What ethics will guide yourdquo

Day six features an interview with Atul Gawande Dallas Morning


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News reporter Seema Yasmin a physician conducted the inter-view Gawande says that he has learned that people have ldquopriori-ties in their lives besides just living longer and they matter a great dealrdquo The best way to learn these priorities is to ask the pa-tient and Gawande says that this is not done frequently enough And when we donrsquot ask the result is that patients frequently get care that does not help them meet their own priorities

Gawande identifies basic questions clinicians should ask pa-tients and be comfortable asking These questions are

ldquoWhatrsquos your understanding of where you are with your illness or your health at this time

What are your fears and worries for the future

What are your goals and priorities if your health worsens

What are you willing to go through and what are you not willing to go through in seeking treatment for more possible timerdquo

The interview with Gawande is summarized in the article and the link to the article includes a video of Gawandersquos appearance on ldquoThe Daily Showrdquo

Each of the daily introductions and more than 100 blog entries are available online (Dallas Morning News 823 Dallas Morning News 824 Dallas Morning News 825 Dallas Morning News 826 Dallas Morning News 827 Dallas Morning News 826)

HOSPICE NOTESbull Journal of Pain and Symptom Management published a study

that reveals good outcomes for hospice patients who receive systematic telephone intervention The study shows ldquohow an innovative telephone intervention program for hospice patients may lead to more efficient resource utilization decreased after-hour calls and most importantly higher sat-isfaction among caregiversrdquo The study demonstrates both the feasibility of such a program and itrsquos acceptability to patients (Journal of Pain and Symptom Management 730)

bull A new study in Journal of Pain and Symptom Management addresses how continuous care in patientsrsquo homes is used by hospices and what impact continuous care has on patient outcomes The researchers hoped to ldquodescribe patients who receive continuous care and determine whether continuous care reduces the likelihood that patients will die in an inpa-tient unit or hospitalrdquo The study finds that the ldquouse of continu-ous care on the day before death is associated with a signifi-cant reduction in the use of inpatient care on the last day of life particularly when patients are cared for by a spouserdquo

(Journal of Pain and Symptom Management 429)

bull A chain of hospices in the south has agreed to settle a whistle-blower lawsuit concerning overbilling Federal prosecutors alleged that the hospice was driving up Medicare payments by billing for continuous care to patients who werenrsquot eligible under federal rules The hospice denies wrongdoing saying that the billing rules were unclear According to an article in the Jackson Mississippi Belleville News-Democrat the hospice will reimburse Medicare for 59 million dollars (Belleville News-Democrat 93)

PALLIATIVE CARE NOTESbull While many people with dementia reside in nursing homes

seventy-five percent live somewhere else within the com-munity Journal of the American Geriatrics Society recently devoted an entire issue to care of dementia patients living in the community ldquoOur nation lacks a coordinated system of formal and informal care to provide for the daily symptom and functional needs of community dwelling people with demen-tiardquo (GeriPal 831)

bull The Pediatric Palliative Care Coalition aims to help those car-ing for children with life-threatening illnesses These children are often not supported by traditional palliative care and hospice organizations Founded in Fox Chapel Presbyterian Church by church members concerned about the gap in care the coalition is currently advocating for two bills in the Penn-sylvania General Assembly involving pediatric palliative care (Pittsburgh Post-Gazette 831)

bull Mountain Xpress in Ashville North Carolina shares a familyrsquos journey through their experience of pediatric palliative care when their daughter is born with a genetic condition They explain that Mission Hospitalrsquos Pediatric Palliative Care team members ldquowere our most trusted advocates and our most trusted advisers in everything I donrsquot know if I even have the words to describe what [the doctor] means to our family The care team was lsquoat our beck and call whenever we needed themrsquordquo (Mountain Xpress 91)

bull A new report from Hospice Analytics and Dr Lisa Lindley shows that Florida hospice providers offer 500 more pediat-ric hospice services than the national average In the soon-to-be published report Pediatric Hospice and Palliative Care A Little Knowledge Goes A Long Way Dr Lindley highlights several reasons why pediatric hospice care can be challenging for hospice providers Florida has tried to address these barri-ers through the Partners In Care Together For Kids (PIC-TFK) program (Press Release Rocket 93)


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bull The new book Essentials of Palliative Care edited by Nalini Va-divelu Alan David Kaye and Jack M Berger ldquoaims to provide ready reference for both generalists and specialists looking for guidance on the many diverse topics that fall under the um-brella of palliative carerdquo The 28 chapters on far reaching topics serve as a ldquopractical orientation for any clinician caring for seri-ously ill patientsrdquo (Journal of Palliative Medicine 092015)

bull An article in the Journal of Clinical Oncology explores the low rates of inpatient palliative care consultations and says the consultations occur close to death The study ldquofound that 16 of white patients 22 of African-American patients and 20 of Hispanic patients had an inpatient palliative care consulta-tionrdquo (Cancer Therapy Advisor 91)

PHYSICIAN ASSISTED SUICIDE NOTESbull George Will writing a NewsOK editorial says he supports

physician-assisted suicide especially the proposed law al-lowing it in California He says ldquoThere is nobility in suffering bravely borne but also in affirming at the end the distinctive human dignity of autonomous choicerdquo (NewsOK 830)

bull A case to allow a physician to aid terminally ill patients in choosing to end their own lives will be heard in New Mexico Supreme Court on Monday October 26 Lower courts have ruled both for and against the existence of a right to die (Santa Fe Reporter 91)

bull A controversial bill to allow physician-assisted suicide for terminally ill patients in California passed its first key legisla-tive committee the Assembly special session committee on health on September 1 The bill had failed in the legislature earlier this summer amid opposition from the Catholic Church and other groups The measure which passed 10-3 next goes to the assembly finance committee (Kaiser Health News 92)

END-OF-LIFE AND OTHER NOTESbull A study and editorial published August 31 in JAMA Internal

Medicine focuses on addressing patientsrsquo spiritual concerns The study highlights the fact that religious or spiritual con-cerns were discussed in only sixteen percent of ICU family meetings When these issues are discussed doctors and other healthcare professionals often fail to address the familyrsquos concerns effectively or directly (HealthDay 831)

bull A study in Journal of Palliative Medicine looks at how a physi-cianrsquos ldquoframingrdquo of healthcare options is known to influence decision-making in a medical setting The researchers describe language used by physicians when discussing treatment options with a critically and terminally ill elder In the high-

fidelity simulation experiment conducted the majority of physicians framed the available options in ways implying life-sustaining treatment was the expected or preferred choice (Journal of Palliative Medicine 092015)

bull In Journal of Palliative Medicine Dr Suchita Shah writes about her experience of her grandmotherrsquos dying Shah says ldquoIt wasnrsquot until I was the family member of a dying patient that I began to understand what had eluded me thus far in my training--that the perceptions and emotions surrounding palliation werenrsquot just logic and reason but were unfamiliarity fear and loverdquo (Journal of Palliative Medicine 092015)

bull Ehsan Dowlati writes in Journal of Palliative Medicine about what he learned from his grandmotherrsquos death and how this learning applies to him as a physician Dowlati says there are three key points that physicians need to keep in mind ldquoFirst is the awareness of the patientrsquos or familyrsquos wishesrdquo Second is to offer care best for the patient ldquoThird is to take into account the patientrsquos future end-of-life care by understanding the consequences of what the patient decides and communicat-ing this to the patient and their family so that they may adjust their expectationsrdquo (Journal of Palliative Medicine 092015)

bull It is now lawful in every state for physicians to write e-pre-scriptions for controlled substances The biggest challenge now says an article in Medscape is to educate clinicians Physicians must update their software which many vendors provide as a no-charge service At this time notes the article only 4 of providers have completed this upgrade (Medscape 831)


POSITION PAPER OFFERS RECOMMENDATION FOR USE OF TELEMEDICINEAnnuals of Internal Medicine has published a position paper from the American College of Physicians (ACP) The paper offers policy recommendations to guide the use of telemedicine in primary care Telemedicine is described as the use of technology to deliver care at a distance Utilization of telemedicine is grow-ing and this growth can potentially expand access for patients enhance patientndashphysician collaboration improve health outcomes and reduce medical costs The potential benefits of telemedicine must however be measured against the risks and challenges associated with its use These risks include the absence of physical examination variation in state practice and licensing regulations and issues surrounding the establishment of the patientndashphysician relationship


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The paper offers policy recommendations for the practice and use of telemedicine in primary care as well as reimbursement policies associated with telemedicine use Reimbursement remains one of the largest challenges for telemedicine as laws and policies vary widely and some areas provide more incentives than others Medicaid for example offers reimbursement in 46 states and the District of Columbia for interactive or live video 10 states reimburse for store-and-forward technology 13 states reimburse for remote monitoring and three pay for all three types of telemedicine The ACP supports payment by public and private health plans whether the telemedicine encounter hap-pens in real time via two-way communication or via transmission of information not in real time They also support this reimburse whether communication is text only or accompanied by voice video or device feeds

The positions put forward by the American College of Physicians highlight an approach to telemedicine policies and regulations that they hope will have lasting positive effect for patients and physicians ACP believes that a valid patientndashphysician relation-ship must be established for a professionally responsible tele-medicine service to take place ACP recommends that telehealth activities address the needs of all patients without disenfranchis-ing financially disadvantaged populations or those with low literacy or low technologic literacy ACP believes that physicians should use their professional judgment about whether the use of telemedicine is appropriate for a patient

In an editorial also in Annals of Internal Medicine Dr David A Asch writes that he believes that the gains from telemedicine will come from delivering care to populations that sometimes require highly specialized care in totally different ways The in-novation that telemedicine promises is not just doing the same thing remotely that used to be done face-to-face but awaken-ing us to the many things that we thought required face-to-face contact but actually do not (Medscape 98 Annals of Internal Medicine 98 Annals of Internal Medicine 98)

CENTER FOR LIVING SERVES CAREGIVERSIn Savannah Georgia the soon-to-open Celeste C and Robert H Demere Jr Center for Living will house several community programs The Center for Living is a new 8400-square-foot $3 million facility and is the creation of the Hospice Foundation of Hospice Savannah The programs which will work indepen-dently of existing hospice services will address caregivers and families dealing with life-limiting conditions

The Institute strives to help people navigate both the logisti-cal challenges and emotional toll of caring for aging family members or friends And while it is a program of the Savannah

Hospice caregivers do not to have someone in hospice to use the support services The work of the Center focuses on four areas The Edel Caregiver Institute ldquoprovides caregivers with what will become one of the countryrsquos finest sources for information training and supportrdquo Full Circle programs another arm of ser-vices are designed to address needs of entire families who have ldquolost a family memberrdquo The Demere Center for Living resources will combine health care professionals volunteers from the com-munity and ldquoprofessional caregiversrdquo who engage caregivers and increase their skills The Steward Center for Palliative care will help ldquoto grow the palliative care servicesrdquo Overall the facility ldquowill be a one-stop shop for people who are caring for others facing life-limiting diseaserdquo

Unlike the nearby Hospice House this facility focuses on those caring for the aging or dying Lifetime membership is offered for $100 ldquoNobody will ever be turned away everrdquo The facility will work with community partners including Mercer Univer-sity Medical School Savannah Campus at Memorial University Medical Center and St JosephrsquosCandler and Armstrong State Universityrsquos Health and Science Department and its physical therapy students A public ribbon cutting is slated for September 25 (Savannah Morning News 98 Savannah Hospice)

HOSPICE NOTESbull Rev Edward F Dobihal Jr the first medical director of the

hospice in new Haven CT died on May 30 The hospice is gen-erally considered to be the first hospice in the US An article in the Hartford Courant shares about Dobihalrsquos efforts with the hospice (Hartford Courant 913)

bull Cedar Valley Hospice Waterloo IA received positive coverage in Cedar Valley Business Monthly Online for their focus on car-ing for their employees Their Employee Engagement Commit-tee makes sure that organization addresses work-life balance professional development and adequate leave (Cedar Valley Business Monthly Online 97)

bull Methodist Hospital in Omaha Nebraska has a growing hos-pice program helping 2000 to 2500 patients since it began in 2012 According to a story on WOWT ldquoThe palliative care team at Methodist works cooperatively with physicians to provide time to discuss your health goals and needs expert manage-ment of pain and other symptoms help navigating the health-care system guidance with difficult and complex treatment choices and emotional and spiritual support for you and your familyrdquo (WOWT 98)

bull Mountain Community Mennonite Church in Palmer Lake Colorado and Pikes Peak Hospice amp Palliative Care have


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partnered together as a part of the hospicersquos Faith Community Initiative to raise awareness about end-of-life issues and the importance of advance care planning They feel that partnering together expresses their belief that ldquoproviding information and options to patients is important at a time when many pastors donrsquot feel up to the job and many doctors feel pressured to prolong life at any costrdquo (The Gazette 419)

bull A hospice in Tennessee has reached an agreement to reimburse the federal government for alleged overbilling of Medicare and TennCare for hospice services The federal government accused the organization of ldquoproviding too much care for seven patients who did not qualify for itrdquo The hospice denies any wrong doing in the settlement but agreed to the settlement siting the desire to avoid legal costs in fighting the charges (The Daily News Journal 911)

END-OF-LIFE NOTESbull The West Virginia Center for End-of-Life Care has given first

responders in the state access to its online registry allowing emergency services workers to see if patients have advance directives before they are admitted to a hospital Advocates say that this will make it more likely that patientsrsquo wishes will be known and respected in emergency situations (The Washington Times 96)

bull Dr Chris Feudtner writes in The Journal of the American Medi-cal Association about his experience of helping parents make end-of-life decisions for critically ill newborn babies He presents both intensive interventions and hospice options so that fami-lies can understand the range of care available (The Journal of the American Medical Association 98)

bull Susan R Dolan a hospice nurse writes in a Huffington Post blog about the importance of catering to dying peoplersquos wishes for particular foods or drinks From her own experience she explains that ldquoAfter months or even years of eating mushy unidentifiable meals a favorite food can seem like heavenly mannardquo She gives advice on how to share special food and drink safely and caringly (Huffington Post 912)

bull Physician Edward Leigh reflects on the ldquodelivery of bad news to patientsrdquo Leigh shares of the way he was dealt with when his mother died and calls for greater presence and sympathy from healthcare professionals He offers several tips and says ldquoBy incorporating the steps outlined in this article you will be able to compassionately help patients facing these difficult life experiencesrdquo (Kevin MD 912)

PALLIATIVE CARE NOTESbull The results of a survey published in Journal of Palliative Medi-

cine reveal that healthcare social workers identify high compe-tence in essential aspects of palliative care Social workers have the potential to provide primary palliative care and contribute to person-family centered care However few programs exist to prepare social workers to work as specialists in palliative or end-of-life settings and respondents identified key areas of practice that need to be integrated into graduate education to ensure that students practitioners and educators are better prepared to maximize the impact of social work (Journal of Palliative Medicine 813)

bull Journal of Palliative Medicine published the results of a survey of fellows The study assessed their attitudes toward and quality of training in palliative care during their fellowship and their perceived preparedness to care for patients at the end of life The researchers say ldquoMany recent oncology fellows are still in-adequately prepared to provide palliative care to their patientsrdquo More than 25 reported not being explicitly taught how to assess prognosis when to refer a patient to hospice or how to conduct a family meeting to discuss treatment options They found significant room for improvement in training of fellows in palliative care (Journal of Palliative Medicine 824)

bull The New York Times shared the work of photographer Ilana Panich-Linsman She follows two families with critically ill chil-dren as the pediatric palliative care team at Dell Childrenrsquos Medi-cal Center of Central Texas in Austin Texas cares for them She is impressed by the care they receive and the ability of parents to adjust to trying circumstances (The New York Times 96)

bull A new study published in JAMA Internal Medicine ldquofound that discontinuing statin therapy for patients in palliative care settings was not only safe but also benefited patientsrsquo quality of life increased satisfaction with care and reduced medica-tion costs ldquoAs patients approach the end of life they usually get more medications and that increase often exacts a toll on their bodies becomes harder to track and increases the risk of side effects and complicationsrdquo said Adeboye Ogunseitan MD assistant professor of Hospital Medicine in the Department of Medicine at Northwestern University and co-author of the paper (Drug Discovery and Development 99)

PHYSICIAN ASSISTED SUICIDE NOTESbull California legislation that would allow doctors to prescribe

life-ending medication to terminally ill patients cleared a major hurdle on 99 when the state Assembly narrowly passed the measure on a 43-34 vote ldquoafter an emotionally wrenching de-


| 14mnhpcorg

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bate that left many legislators in tearsrdquo The bill then went to the Senate on 911 After a final emotional debate at the Capitol the California state Senate on Friday voted 23 to 14 to send the End of Life Option Act to Governor Brown to sign into law The measure would allow physicians to prescribe life ending medi-cation after a patient makes two verbal requests of a physician at least 15 days apart as well as providing a written request Two witnesses would be required for the written request to attest that the patient is of sound mind and not under duress The cur-rent version of the measure includes a sunset clause requiring the Legislature to review its implementation in 10 years It also allows physicians to choose not to prescribe end-of-life drugs to a patient (San Jose Mercury News 99 Capitol Public Radio 911)

bull Dr M John Rowe III died in 2014 from drugs made available through Oregonrsquos controversial Death with Dignity Act Rowe wrote in an editorial published posthumously this month in The Journal of the American Medical Association saying ldquoI believe that our first duty as physicians is to relieve pain and suffering whether it be physical or emotional Only then secondarily are we to avoid harming the patientrdquo Based on this conviction Dr Rowe argues that physician assisted suicide is something that falls within a moral medical framework (The Journal of the American Medical Association 91 Life Matters Media 97)

OTHER NOTESbull Ken Covinsky writing in Geripal explains that new high tech

devices that monitor patients every movement are often det-rimental They provide too much data and also isolate seniors from human interaction ldquoMy advice to entrepreneurs and ven-ture capitalists Think high touch before high tech What kinds of innovations will actually improve the quality of life of older people and make them feel better and promote social engage-mentrdquo (Geripal 97)

bull An analysis of Medicare records and surveys reveals that doctors struggle to deliver an Alzheimerrsquos diagnosis to patients and their caregivers According to the 2015 Alzheimerrsquos Disease Facts and Figures report released by the Alzheimerrsquos Association this week only 45 percent of people who suffer from the disease or their caregivers said their doctor gave them the diagnosis Among the reasons cited for why patients are not told of their Alzheimerrsquos diagnosis were time constraints difficulty in deliver-ing the news fear of causing emotional distress and diagnostic uncertainty (Associations Now 326)

bull In Dr David Casarettrsquos book Stoned A Doctorrsquos Case for Medical Marijuana he says that medical marijuana is ldquonot pseudosci-ence after allrdquo When writing the book he interviewed dozens

of patients and doctors visited dispensaries and tried mari-juana to relieve his back pain ldquoTaking controlrdquo is the phrase he heard repeatedly from patients who turned to marijuana after mainstream drugs failed to alleviate their symptoms ldquoYes it has side effectsrdquo they told Casarett ldquoBut so do FDA-approved drugsrdquo (Chicago Tribune 910)

bull Back-to-school time can often be particularly hard on children who are grieving the loss of a loved one Karen Monts director of grief support services at Hospice of Michigan explains ldquoIf a child has recently lost a parent it can be difficult to hear other children talking about their families And while father-daughter dances and grandparents day are special and fun-filled events they can be painful reminders of loss to a grieving childrdquo It can be difficult to recognize a child who is struggling with grief because grief is a feeling young children canrsquot verbalize well Instead feelings of grief in children typically come out in behaviors and actions Educators and other adults should keep any eye out for unusual behavior as a sign that a child is having problems coping with loss (The Cedar Springs Post 911)

bull Obituaries particularly funny or unusual ones are going viral with millions of shares and likes on social media Unlike when obituaries were just published in papers ldquodeath notices are much easier to submit and share thanks to local news websites tribute pages hosted by funeral homes and the clearinghouse legacycom which claims 24 million unique visitors a month and maintains a whole section of lsquoFunny Obituariesrsquo As a conse-quence amateur obituarists are having more fun with the staid genre and receiving more attention for their effortsrdquo (Dallas News 94)


MEDICARE LOOKING FOR WAYS TO HOLD DOWN HOSPICE COSTSSeeking to avoid a system that leads to frequent double-payment officials at Medicare are considering alternatives to the way that hospice care is presently funded A recent article in Kaiser Health News examines the considerations that are taking place within the federal agency about how the Medicare hospice benefit should be structured Yet says the article ldquoPatient advocates and hospice providers fear a new policy could make the often difficult decision to move into hospice care even harderrdquo

While Medicare-funded hospice patients agree to forgo curative treatments for their terminal illness and instead to receive pallia-tive care Medicare patients are still eligible to receive coverage for conditions that are not related to their terminal illness For


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example accidental injuries and chronic health conditions would still be covered despite a patientrsquos hospice status

From Medicarersquos perspective the problem arises when they are forced to pay for services twice ldquoMedicare pays a set amount to the hospice provider for all treatment and services related to the terminal illness including doctorrsquos visits nursing home stays hos-pitalization medical equipment and drugsrdquo But care that does not directly relate to the terminal condition is covered by additional funds drawing on regular non-hospice Medicare benefits

ldquoIf a patient needs treatment that hospice doesnrsquot provide because it is not related to the terminal illness ndash or the patient seeks care outside of hospice ndash Medicare pays the non-hospice providers The problem is that sometimes Medicare pays for care outside the hospice benefit that it already paid hospice to coverrdquo In order to prevent such duplicate expenditures Medicare has announced that it is considering whether CMS should assume that ldquovirtually allrdquo the care that hospice patients receive should be considered as covered under the hospice benefit

If this were the case hospice organizations would no longer be able to easily refer patients to non-hospice providers ndash a practice that is currently common but which diverts costs away from hospices and onto Medicare ldquoMedicare has been paying millions of dollars in recent years to non-hospice providers for care for terminally ill patients under hospice care according to government reportsrdquo

The numbers involved are quite large MedPAC found that in 2012 Medicare paid roughly $1 billion to non-hospice service providers for services unrelated to the patientsrsquo terminal illness ldquoThe com-mission did not estimate how much of that was incorrectly billed and should have been covered by hospices Prescription drug plans received more than $33 million in 2009 for drugs that prob-ably should have been covered by the hospice benefit accord-ing to an investigation by the Department of Health and Human Servicesrsquo inspector generalrdquo

Medicare officials mentioned last year that changes to the hospice benefit payment system were potentially in the works citing concerns about duplicate payments Such duplication they said ldquostrongly suggests that hospice services are being lsquounbundledrsquo negating the hospice philosophy of comprehensive holistic care and shifting the costs to other parts of Medicare and creating additional cost-sharing burden to those vulnerable Medicare ben-eficiaries who are at end-of-liferdquo

Yet some seniorsrsquo advocates are concerned that a shift by Medi-care to place all coverage under the hospice benefit could block patients from receiving the care they need Rather than a blanket change to the way the hospice benefit is treated they suggest that

Medicare should instead pursue action against particular hospice providers that shift costs in ways that are unethical

While it is tempting to simply create blanket changes in the law this could cause great hardship for terminally ill patients with diabetes for example ldquoIf your blood sugar gets out of control that could hasten your deathrdquo says Terry Berthelot senior attorney at the Center for Medicare Advocacy ldquoBut people shouldnrsquot be rushed off to die because theyrsquove elected the hospice benefitrdquo (Kaiser Health News 423)

CANCER SPECIALISTS CONSIDER HOW TO FACILITATE ADVANCE CARE PLANNING CONVERSATIONSWriting for the journal Oncology Drs Taira Everett Norals and Thomas J Smith discuss the importance of advance care planning conversations and how they as physicians specializing in cancer treatment should handle such conversations with their patients ldquoRecent data suggest that we are not successfully getting the message across about the importance of advance care planning for patients who have a life-ending illnessrdquo Norals and Smith argue that physician leadership in initiating advance care planning con-versations is key to helping break through denial and in produc-ing outcomes that lead to higher quality of life for terminally- ill patients

Without interventions by physicians to clarify the medical realities of a terminal prognosis many patients are likely to come to false conclusions ldquoHalf to three-quarters of patients with incurable can-cer think that they may be cured by chemotherapy radiation or surgery hellip This avoidance has consequences since those patients with lsquoprognostic awarenessrsquo have end of life care pathways that involve little use of the hospital ICU end-of-life chemo or lsquocodesrsquo with almost no chance of success and much more dying at home with hospice carerdquo

Norals and Smith say that physician-initiated advance care plan-ning can help ensure better results by bringing a dose of compas-sionate realism to patients who may have no other source for accurate information about their condition and prognosis ldquoIf we can successfully initiate advance care planning discussions with our patients and families their end-of-life processes will improve resulting in better care less use of the hospital and more honoring of newly discerned choicesrdquo

The authors provide several recommendations for physicians who want to deepen their competency and facility with leading advance care conversations First they recommend that doctors ldquodispel some of the myths that suggest advance care planning and code discussions are harmfulrdquo They also say that every oncologist


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should be well versed in what they call ldquoprimary palliative carerdquo - the quotidian skills of caring for and communicating with seriously ill patients

Norals and Smith provide some guidance for how to get these often-intimidating conversations started How are such conversa-tions started First physicians must recognize that the patient desires the conversation Many patients already have advance directives but have not told anyone about them Second itrsquos cru-cial that doctors really get to know their patients Conversations of such depth as end-of-life planning are far less awkward when you actually know the person yoursquore speaking with Finally the authors recommend that all physicians should have a good grasp of the typical outcomes of resuscitation among different patient groups ndash depending on age and condition This knowledge will directly impact recommendations on DNRAND orders

ldquoUnfortunately care is becoming more intense during the last month of life with increased use of the hospital and ICU and short hospice stays ndash all indicators of both poor quality of care and missed opportunities for discussions of EOL goals and plansrdquo the authors conclude ldquoAll the available evidence says that asking patients about their EOL preferences early in the disease trajectory and making sure that palliative care skills are brought to bear will improve their carerdquo (Oncology 815)

HOSPICE NOTES bull Hospice of the Western Reserve and HMC Hospice of Medina

County have completed a merger The two Ohio hospices say that no layoffs are planned Each organization will continue to use its own name for the next year after which the entire hospice will operate under the name ldquoHospice of the Western Reserverdquo (Crainrsquos Cleveland Business 914)

bull The CEO of a Tennessee hospice is responding to allegations of overbilling Medicare and TennCare for hospice services The hos-pice leader states that the organization ldquohas voluntarily reached a settlement with the US Department of Justice and the Tennes-see attorney generalrdquo She says ldquoThis matter is in no way related to the delivery of quality carerdquo (Lebanon Democrat 915)

bull A hospice facility and its manager operating in the states of Mis-sissippi Louisiana Texas and Alabama have been ordered to pay approximately $586 million to resolve allegations of fraud in continuous home care hospice (US Department of Justice 93)

END-OF-LIFE NOTESbull Even if doctors want to be clear and honest with patients that

may not always be what patients themselves desire An article

published in The Journal of the American Medical Association concludes that patients perceive ldquoa higher level of compas-sion and preferred physicians who provided a more optimistic message More research is needed in structuring less optimistic message content to support health care professionals in deliver-ing less optimistic newsrdquo (JAMA 915)

bull Modern death has its own characteristic rituals Haider Javed Warraich shares his own experience as a physician pronouncing the death of individuals in a hospital and the ritualistic patterns that accompany death in modern America The rituals he says used to be different ndash and they can be different again (The New York Times 916)

bull Nevada Public Radio features a story on a new program that seeks to train more end-of-life caregivers ldquoOne year into its medical fellowship program for end of life care partners Nathan Adelson Hospice and Touro University are claiming successrdquo (NPR 916)

bull Dr Kenneth W Lin MD MPH explores what it means to move beyond the rhetoric of ldquodeath panelsrdquo in a video commentary published on Medscape ldquoLittle seems to have changed since I was a medical student 15 years ago and placed a chest tube in a near-comatose patient within days of his death and also partici-pated in the failed cardiopulmonary resuscitation of an elderly woman with metastatic colorectal cancerrdquo (Medscape 910)

bull What really matters at the end of life Dr BJ Miller a palliative care doctor and Executive Director of San Franciscorsquos Zen Hos-pice Project shares insights about end-of-life care in the recent TED Talk ldquoWhat Really Matters at the End of Liferdquo (Legacy 911)

bull Preparing for the end of life is powerful The Star Tribune tells the story of a 71-year-old woman who died after firefighters de-cided to suspend life-saving measures There was grief and con-fusion in her treatment and death ldquoIf there had been a POLST form I think it would have been a nonissuerdquo (Star Tribune 912)

bull Erica Jong has published a new book exploring the ldquoFear of Dyingrdquo and one review is not favorable ldquoAs undisciplined as a spoiled child it lacks both palpable plot and real characters other than its frazzled and self-involved narrator lsquoDyingrsquo is a collection of distractions not a cohesive work of fictionrdquo (Buffalo News 913)

bull Jessica Vogelsang writes about what her motherrsquos death taught her about the incredible attachment many of us have to ani-mals (The Huffington Post 910)

bull Sara Bobkoff describes the ldquomiraclerdquo of her fatherrsquos death ldquoAll that was left of his autobiography was my sister myself and the soft white pearls of what were once his thick black curly hairrdquo


| 17mnhpcorg

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(The Huffington Post 916)

bull Dr James Stalwitz writing in KevinMD blog shares a referral he writes for his patient ldquoMr Ron Crdquo Stalwitz shares that he gave the patient choices for interventions to deal with his metastatic lung cancer He included in these choices the options to do nothing But Mr C saw this as desertion and now wants to choose another doctor The blog shows the risks of such an offer and explores the dilemma it presents to both physician and patient (KevinMD 914)

bull Dr Earl Stewart Jr writes in KevinMD about caring for dying patients Stewart says ldquoCaring for the dying patient is as much a challenge as it is rewarding It is a challenge because no longer are we tasked with the job of ascertaining a treatment and sometimes cure for a potentially reversible medical illness but our chief purpose in care at that point is to maximize comfortrdquo This difficult work says Stewart calls for recognizing that the end of life is as significant as the beginning of life (KevinMD 917)

PALLIATIVE CARE NOTESbull Raceethnicity doesnrsquot seem to play a major role in the quality

of inpatient palliative care received by patients Thatrsquos the good news The bad news is that rates of inpatient palliative care remain low across the board (Journal of Clinical Oncology 831)

bull Robert Fine MD FACP FAAHPM clinical director of the Office of Clinical Ethics and Palliative Care at Baylor Scott amp White Health writes about the changes in palliative care that hersquos seeing in his work Fine makes an organizational case for palliative care Lead-ers at Baylor Scott amp White Health have developed a program to lower costs improve quality and reduce readmissions (Health Leaders Media 831)

bull An article in Journal Star Peoria IL tells the story of the work and successes of the palliative care program Dr Phillip Ols-son medical director of OSF Hospice and the Richard L Owens Hospice Home shares about the work of palliative care and the benefits to patients and families (Star Tribune 916)

bull The end-of-life choices of one dying man in Albuquerque high-lights the value of palliative care at the end of life These choices also reveal the dignity that can come with accepting a terminal prognosis with equanimity and poise Albuquerque Journal printed ldquoSeeking comfort in his final daysrdquo the story of Norbert Schueller who is dying with throat cancer Schueller declined medical treatments that would leave ldquohim unable to eat by mouth and unable to speak plus weeks of debilitating chemo-therapy and prescriptions for painkillersrdquo He wrote a letter to the cancer center leadership in early September asking ldquoWhy

chemotherapy when the drugs will not cure the cancer Why addictive mind-numbing painkillers when ibuprofen would suffice Why had the medical process become as complicated and complex as the legal processrdquo Schueller is seeking palliative care instead of hoping for a cure Schueller says ldquolsquoIt seems to me that when the medical circumstances indicate imminent death palliative care means making the patient comfortable and reducing pain since a cure cannot be effectuatedrsquordquo New Mexico ldquoearned a lsquoCrsquo grade from the National Palliative Care Research Center because less than half of all hospitals in the state with 50 beds or more offer a palliative care programrdquo The University of New Mexico will begin providing palliative care training in 2016 Norbertrsquos (Albuquerque Journal 917)

PHYSICIAN ASSISTED SUICIDE NOTESbull A bill that would legalize physician-assisted suicide has reached

the desk of California Governor Jerry Brown ldquoIf Gov Jerry Brown signs the bill California would become the fifth state to allow doctors to prescribe lethal medication to terminally ill patients who request it after Oregon Washington Vermont and Mon-tanardquo (Newsweek 914)

bull Supporters of ldquothe right to dierdquo in New York State are encour-aged by the progress of PAS legislation in California ldquoWe expect New York to follow California in passing death-with-dignity legislationrdquo says Sen Diane Savino (D-Staten Island) (Syracusecom 915)

bull While physician-assisted suicide is unethical says Lynn A Jan-sen the voluntary cessation of eating and drinking (VSED) at the end of life can be morally acceptable Yet even voluntary cessa-tion of eating and drinking is fraught with ethical questions ldquoAd-vocates for PAS often present VSED as an alternative treatment option for end of life suffering that avoids moral controversy But in reality VSED raises challenging moral questions about the permissibility of physician collaboration in patient decisions to end their lives as a means to ending their sufferingrdquo (Annals of Family Medicine 9-102015)

PAIN NOTESbull The CDC says that opioids are ldquonot preferredrdquo as treatment for

chronic pain ldquoNew draft guidelines [could] sharply reduce the prescribing of opioids for both chronic and acute pain in the US The proposed guidelines may also trigger a turf battle between the CDC and the Food and Drug Administration over which agency has primary responsibility for the safe prescribing of medicationrdquo (Pain News Network 916)

bull Proposed legislation in Massachusetts would ban prescrib-


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ing OxyContin to children ldquoThe bill would ban the drug being given to Massachusetts residents under 17 in hospitals or being dispensed from pharmacies even if they have a prescriptionrdquo (Mass Live 916)

Correction In last weekrsquos HNN (Volume 19 number 33) Rev Edward F Dobihal Jr was erroneously identified as the first medical director of the hospice in New Haven Connecticut Rev Dobihal was a founder of the hospice and the first chairman of the board


ARTICLE EXPLORES THE COMPLEXITY OF GRIEFWhen Marion Britts lost her husband in 2006 she experienced numbness so profound that she often couldnrsquot even remember where certain stores in her hometown were located And that was just the beginning When she finally began to feel the impact of the loss it was almost overwhelming ldquoBut accepting her husbandrsquos death was the hardest she said After 27 years of marriage She not only had to deal with the immediate loss but his long-term absence Shersquod have to grow older move out of their house and build a life with only his memoryrdquo

In a piece for Bangor Daily News Erin Rhoda tells the story of one womanrsquos grief and explores how ldquocomplicated griefrdquo can and does affect many Americans who experience the loss of loved ones ndash often repeatedly throughout their lives ldquoFor many the heartbreak-ing reality of aging is a steady stream of loss People may lose a spouse their best friends their siblings Some may lose a son or daughterrdquo In the case of Marion Britts her grief was compounded as she experienced not only the loss of her husband but of her parents and several friends as well

Rhoda argues that with Mainersquos over-65 population likely to dou-ble by 2030 widespread loss and grief is inevitable ldquoIf anything is needed itrsquos a wider understanding of the nuanced nature of sor-rowrdquo In this essay Rhoda lays out the many unknowns of grief the way that sorrow is a reflection of love and a realistic picture of the enduring nature of grief that can be adjusted to but never completely banished

Despite the universal nature of grief surprisingly little research has been conducted on how it affects us ldquoTo date no grief stage theory has been able to account for how people cope with loss why they experience varying degrees and types of distress at dif-ferent times and how or when they adjust to a life without their loved one over timerdquo according to a 2009 report by researchers with the University of California at San Diego in the journal World Psychiatry

ldquoComplicated griefrdquo is a condition that sometimes develops par-ticularly in older adults and which warrants attention by clinicians Complicated grief tends to occur when an individual is unable to accept the death of a loved one and is unable to move on with their lives even years later Nevertheless ldquocomplicated griefrdquo is still a disputed term and therersquos no consensus on how to define it clinically

The symptoms of complicated grief are still under discussion in the medical community and it is also unclear what causes some individuals to develop the condition Recent studies do seem to indicate that complicated grief is more of a risk in older individuals over age 60 ndash somewhere between 7 and 15

Complicated grief can result in behaviors that lock the bereaved into a state of constant mourning Rhoda tells the story of a wom-an who slept on the couch every night because she couldnrsquot bear to sleep on the bed she and her husband shared Her husband had passed away four years earlier This same woman ldquostill kept meals shersquod made for him in the freezer and couldnrsquot prepare regular meals for herself because she missed him so much She wished she could die to be with himrdquo

How can people with such deep grief find healing Rhoda indicates that the biggest step in moving forward from a place of incapacitating sorrow is to simply speak about the loved one how they died and to take time to process the grief with another person They can ldquoshare positive and negative memories of their loved ones and focus on their own goals and aspirations to help them rediscover activities they enjoyrdquo

ldquoGrief is the form that love takes after someone you love diesrdquo says M Katherine Shear a professor of psychiatry at Columbia Univer-sity and director of its Center for Complicated Grief ldquoThe point isnrsquot to put these feelings behind you altogether thatrsquos not possible or even desirable The point is to gain perspective and help grief find its rightful place in a personrsquos liferdquo

This simple yet important therapy seems to be working Almost three quarters of older adults were ldquolsquomuch improvedrsquo or lsquovery much improvedrsquordquo after having these conversations ldquocompared with only 32 who used a previous psychotherapy methodrdquo

Half the battle however is encouraging the bereaved to seek professional help when needed ldquoThere is an online tool offered by the Center for Research on End-of-Life Care at Weill Cornell Medical College in New York that allows people to measure the intensity of their grief After answering a few questions the scale will suggest whether people should see a mental health profes-sionalrdquo The tool provides an image of the various ways that people respond to grief and many will find that they do not fall into the ldquocomplicated griefrdquo category


| 19mnhpcorg

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George A Bonanno director of the Loss Trauma and Emotion Lab at Columbia University Teachers College has found that many bereaved people ndash perhaps between one and two thirds of those who experience a major loss ndash are able to work through the trauma on their own ldquoThey do feel deeply saddened perhaps for a few days to a few weeks But then they are able to carry on with their life Itrsquos not that they donrsquot care They are simply able to ac-cept the loss and move onrdquo

Some others says Bonanno follow a grief pattern that falls some-where between full recovery and complicated grief ldquoThe people in this group feel intense grief and suffering perhaps for as long as a year and then start to return to their former selves But the sad-ness lingers even though they are mostly healthy They may say things like lsquoYou never fully get over itrsquordquo (Bangor Daily News 925 Center for Research on End-of-Life Care at Weill Cornell Medical College)

HOSPICE NOTESbull CMS will test ldquovalue-basedrdquo insurance design in its Medicare Ad-

vantage program ldquoWhile CMSrsquos demonstration model will allow for reduced cost sharing and other benefit design elements to encourage targeted use of high-value clinical services Medicare Advantage Organizations should be aware of certain inherent legal risksrdquo (JDSupra Business Advisor 917)

bull The Portland Press Herald tells the story of how one nurse came to gain an appreciation for just how important hospice care is ldquoThe patient defines how they want to live the rest of their life after getting a terminal diagnosis and we help them achieve thatrdquo said Diane La Rochelle (Portland Press Herald 920)

bull A horse visits hospice to say goodbye to its terminally ill owner ldquoAfter three weeks apart 49-year-old Lisa Beech was visited by her beloved horse Jake in a touching reunion caught on cam-erardquo (Inside Edition 924)

bull Dermatologist Rick Sontheimer posting on KevinMD reflects on the intense suffering of his mother as she neared the end of her life He describes the decline into imminent death and the suffering that people experience His mother longed to die After his experience with her he says ldquoAnd when it comes to end-of-life care perhaps we do need a bigger hammer But that hammer needs to be wrapped in the softest and loveliest of velvets And that gentle hammer needs to be made readily available to anyone whose mind remains sharp as they near the end of their final journeyrdquo At the very end of her life Sontheimer says ldquothe angels of Hospice were finally able to help my mother in her time of need when neither she herself nor I couldrdquo (KevinMD 925)

END-OF-LIFE NOTESbull A Viewpoint article in The Journal of the American Medical As-

sociation emphasizes the importance of considering patientsrsquo actual values when developing an effective values-based payment system ldquoHaving payers aim for value should improve health system performance certainly when compared with tra-ditional incentives for the volume of services which have failed to deliver the kind of care that is possiblerdquo Decisions should be made on two factors says the article ldquoTwo categories are important priorities that matter to most frail or disabled people and those that are important to the specific individualrdquo ldquoIf the United States intends to pay on the basis of valuerdquo concludes the article ldquoit is essential to ask patients what they value and then deliver on those prioritiesrdquo (JAMA 917)

bull Is the choice of whether a loved one has a DNR order really a choice An article in The Journal of the American Medical As-sociation suggests that clinicians may do families a favor by not putting them in the position to make life-and-death decisions for their loved ones Instead says the article physicians can tell patientsfamilies that CPR is not an acceptable choice explain the situation and ask for affirmation Be sure patientsfamily members know that care will continue to be given and that comfort will be the goal ldquoHonoring patientrsquos autonomy by help-ing them to make informed medical decisions is deeply respect-ful of their right to self-determination However presenting CPR as an appropriate treatment option and asking patients or surrogates to choose between CPR and DNR for imminently and irreversible dying patients does nothing to enhance autonomy and can harm survivorsrdquo (JAMA Internal Medicine 92015)

bull Alzheimerrsquos symptoms can make end-of-life conversations a whole lot harder In a recent installment of NPRrsquos ldquoInside Alzheimerrsquosrdquo series one couple discusses the ethical dimensions of not treating the husbandrsquos prostate cancer with the hope that he will die from the cancer before he loses his identity to Alzheimerrsquos (NPR 919)

bull The benefits of contemplative practices are increasingly valued in the United States and they may be particularly relevant in the context of end-of-life care In a video with Sonima Susan Bauer-Wu discusses her book ldquoLeaves Falling Gentlyrdquo ldquoBauer-Wu explains how a contemplative practice can help patients facing a life-limiting illness learn how to be more calm think more clearly accept love and care and make the most of the time they haverdquo (Sonima 919)

bull With the US population rapidly aging do we have the medical personnel with the training that will be required to care for us Marcy Cottrell Houle writes for The New York Times that our


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aging population lacks doctors trained to meet this challenge ldquoMost health care professionals have had little to no training in the care of older adults Currently 97 percent of all medi-cal students in the United States do not take a single course in geriatricsrdquo (The New York Times 923)

bull How do we measure quality of care for the sickest patients Though we spend roughly half of our health care costs on the sickest five percent of patients itrsquos not clear that our medical system is geared to what is best for the most ill patients Diane Meier MD argues ldquoIf quality measurement is to achieve its purpose the health care system must define and measure the outcomes that matter to the people at highest risk of neglect undertreatment overtreatment and suffering Cost contain-ment is urgent and necessary But so is protection for the patients most in need of care and least able to advocate for themselvesrdquo (Harvard Business Review 918)

bull A Texas man speaks about the experience of receiving a heart transplant and the ldquosurvivorrsquos guiltrdquo that he experiences (Lub-bock Avalanche-Journal 917)

bull In a video posted by Inside Edition a 92-year-old husband serenades his dying wife with a World War II-era song A grand-daughter who was present in the hospital with her family captured the video (Inside Edition 921)

PALLIATIVE CARE NOTESbull An article published in The Journal of Palliative Medicine

explores the views of clergy on what constitutes a ldquogood deathrdquo and a ldquobad deathrdquo Researchers found that clergy characterized a good death as being one with ldquowholeness and certainty and emphasized being in relationship with God Conversely a lsquopoor deathrsquo was characterized by separation doubt and isolationrdquo The clergy surveyed described four key determining factors in whether an individual experienced a good poor or ldquomiddlerdquo death ldquodignity preparedness physical suffering and commu-nityrdquo (The Journal of Palliative Medicine online 828)

bull The American Hospital Association has released an ICU pallia-tive care toolkit meant to help hospitals clinicians and patients ldquoencourage early intervention and discussion about priorities for medical care in the context of progressive disease and robust communication between patients and their providers to under-stand the patientrsquos goalsrdquo (AHA 92015)

bull The California Health Care Foundation has announced the cre-ation of the Community-Based Palliative Care (CBPC) Resource Center The Center provides strategies and support for organiza-tions that are planning implementing or enhancing an outpa-tient CBPC program ndash including key concepts best practices

program descriptions and a variety of tools for implementing programs (CHCF 72015)

bull The CDC has issued draft guidelines for prescribing opioids for chronic pain The CDC is requesting comments from stakehold-ers The National Hospice amp Palliative Care Organization has given its response stating that it is ldquopleased that the guidelines exclude patients who are at the end of life with language that states lsquooutside end-of-life carersquordquo Nevertheless NHPCO shares several concerns it has with the draft guidelines including the short timeline of the commenting period an apparent lack of documentation behind the guidelines and potential risks to vulnerable populations such as the elderly and those with cog-nitive impairment Meanwhile Pat Anson at Pain News Network questions whether the new guidelines have more to do with special interests than with patient care (CDC 918 NHPCO 918 Pain News Network 924)


| 21mnhpcorg

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CALENDAR OF EVENTSOCTOBER

102 mdash MCDES Fall Conference When Death EntersThis collaborative workshop will set forth a clinical understanding of the often unconscious forces (counter transference) that can create positive and negative outcomes at the profound interface of life and death

Full details amp registration information httpbitly1EBsPdU

103 mdash Annual North Memorial GalaNorth Memorial hosts a gala that helps to fund specific hospital initiatives Since 1987 these galas have raised more than $3 million and funded a variety of program enhancements in areas such as rehabilitation cancer care stroke and heart centers emergency and trauma services hospice care women and childrenrsquos services The festive evening includes silent and live auctions dinner raffle live music and dancing

Full details amp registration information httpbitly1LXt4wQ

107-108 mdash Advance Care Planning TrainingHonoring Choices Minnesota offers First Steps Facilitator Training twice each year at its Minneapolis site and offers First Steps Instructor Certification Training and First Steps Design amp Implementation Training periodically when there is a demonstrated need

Full details amp registration information httpbitly1WtiJAd

108 mdash Minding Our EldersCarol Bradley-Bursack author of Minding Our Elders will be the Keynote Speaker at Horizon Center She will take you on a journey into the life of a caregiver while sharing her experiences and her heartwarming stories Carol works as a consultant on aging and caregiving issues Her elder care newspaper column ldquoMinding Our Eldersrdquo runs weekly in print and on-line

Full details amp registration information httpbitly1P1uls0

1010 mdash World Hospice and Palliative Care DayWorld Hospice and Palliative Care Day is a unified day of action to celebrate and support hospice and palliative care around the world

Full details httpwwwthewhpcaorgabout

1013 mdash Optimizing Care for the Seriously Ill amp Dying PatientThe purpose of this conference is to provide healthcare professionals with education and resources to support and care for the seriously ill and dying patients and their families

Full details amp registration information httpbitly1KOokcV

1021 mdash On the Road with NGS MedicareHonoring Choices Minnesota offers First Steps Facilitator Training twice each year at its Minneapolis site and offers First Steps Instructor Certification Training and First Steps Design amp Implementation Training periodically when there is a demonstrated need

Full details amp registration information httpbitly1h34Vwi

1021 mdash Caring Science Conscious Dying Principles amp PracticesExplore ldquoConscious Dying Principles and Practicesrdquo ndash a sacred philosophy and new primary palliative practice as a sacred passage and transformative healing journey including exploration of the spiritual and emotional practicesrituals necessary for dying patients to transition with grace inside their own beliefs and practices

Full details amp registration information httpbitly1LXw0K6

1027 mdash Grief Support Services Fall ConferenceIn the first half of this seminar participants will come away with a deeper appreciation for the state of grief counseling in 2015 and become better prepared to implement practical effective strategies for assisting grieving individuals and families The second half of the program will teach participants specific strategies for nurturing their compassionate hearts even as they work in the trenches each and every day

Full details amp registration information httpbitly1NPNWvK

2365 McKnight Road North Suite 2 North Saint Paul MN 55109

6519174628 | 8002149597 wwwmnhpcorg


| 22mnhpcorg

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MEMBER BENEFITS Not a member yet Become one todayAs a member you can access full job descriptions on the MNHPC website Visit wwwmnhpcorg and click on ldquoJob Boardrdquo under the top navigation bar

If you have any questions please call (651) 917-4616 Please also contact MNHPC if you have filled a position that is listed and should be removed from the Job Board list We will automatically remove jobs after four months unless we hear from you

MNHPC members may post a job opening by emailing the following information to MNHPC at infomnhpcorg

MNHPC Staff

bullSusan Marschalk ExecutiveDirectorSmarschalkmnhpcorg

bullReneacutee Mungas ProgramManagerRmungasmnhpcorg

bullHannah Onderko CommunicationsandDevelopmentCoordinatorHannahmnhpcorg

bullKaren DaltonEventCoordinatorKarenmnhpcorg

bullEmma Radke GraphicDesigner

JOB OPPORTUNITIESCNA NC Little Hospice

Hospice AideTMA Seasons Hospice

Hospice Aide Seasons Hospice

RN (05 FTE) Seasons Hospice


Accounting Associate-AP Seasons Hospice

Casual Hospice Aide CHI St Josephrsquos Health

Hospice After Hours RN Hospice of the Twin Cities

RN Case Manager Hospice Ridgeview Medical Center

Performance Improvement Coordinator Our Lady of Peace Hospice

Nurse Practitioner Fairview Home Care and Hospice

bull Name of organization

bull Job title amp description

bull Contact information

bull Closing date


| 2mnhpcorg

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World Hospice and Palliative Care Day is a unified day of action to celebrate and support hospice and palliative care around the world

This yearrsquos theme for World Hospice and Palliative Care Day is ldquoHidden Lives Hidden Patientsrdquo This yearrsquos theme will focus on the patients living in unique conditions that often struggle with access to palliative care including children LGBT individuals HIV prisoners soldiers and those living in rural settings

Aims of World Hospice and Palliative Care Day

bull To share our vision to increase the availability of hospice and palliative care throughout the world by creating opportunities to speak out about the issues

bull To raise awareness and understanding of the needs ndash medical social practical spiritual ndash of people living with a life limiting illness and their families

bull To raise funds to support and develop hospice and palliative care services around the world

2016 MNHPC Annual ConferenceCall for Proposals is Now Open

Visit the MNHPC website for full details on the conference and proposal guidelines

On MNHPCrsquos website you will findbull Important dates and deadlinesbull The goal of the 2016 conferencebull The conferencersquos target audiencebull 2016 Areas of Emphasisbull Types of Presentationsbull Levels of Presentationsbull Instructions on submitting your proposal


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6519174628 | 8002149597 wwwmnhpcorg


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6519174628 | 8002149597 wwwmnhpcorg


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