New end-of-life program inspires STC nursing students
2010-09-23 23:46:28
WESLACO — Six South Texas College nursing students pondered how they would prepare for the possibility of their own imminent deaths, sitting just doors away from four patients facing that very situation.
It was no surprise the exercise drew tears in the quiet room, said Naila Rodriguez, one of the students in a new end-of-life care program at STC.
The nursing group spent their entire Tuesday at Aurora House, a Weslaco-based specialty care center for patients with a handful of months left to live.
“Imagine saying goodbye to your kids — your everything,” Rodriguez said. “What goes through your head as death comes in a few months? What do you tell your family? This gives us patience when a patient is impossible and we don’t know why.”
Partnered with Aurora House, STC recently adopted a new pilot program this semester to teach soon-to-be nurses a four-pronged palliative care approach to hospice and end-of-life treatment. The program is the first of its kind in the Rio Grande Valley.
“Physicians can’t move on and just fix the physical pain,” said program director Dr. Raphael Rodriguez. “There’s still spiritual, psychological and social pains that can make a patient’s experience worse.”
After drafting the program, Dr. Rodriguez persuaded the college to send six fourth-semester students to the care center each week.
There, a chaplain, social worker and doctor teach them how to help dying patients overcome mental, spiritual and emotional distress.
Palliative care has grown in popularity around the country as nurses more frequently act as intermediaries between overworked doctors and worried patients and families.
The American Association of Colleges of Nursing emphasized the need for better end-of-life care in 1997, and Chelan Williams, a nursing instructor at STC, said the Valley is finally catching up.
“The philosophy is not to prolong suffering or hasten death,” Williams said. “The Valley is still years behind in the entire medical field.
Dr. Rodriguez hopes to instill that individual-based approach in the students rotating through Aurora House. The facility sees six new students each week but exhaustively explains the overwhelming list of non-physical symptoms that often tax patients’ well-being.
On Tuesday, the students listened intently to a Knapp Medical Center chaplain as he discussed the communication barriers nurses can dissolve by staying aware of the patient’s belief in prayer, differences in relatives’ religions or worry of the afterlife.
Afterward, Naila Rodriguez and her peers began evaluations on a younger male patient.
Though the students asked if he would like to be moved or made more comfortable, he admitted he would not mind passing away soon.
“Every patient — not just those that know they’re dying — can hurt more than pain,” Naila Rodriguez said. “We can use these lessons for any type of patient. Hospitals or long-term care do not have to be so sad or scary.”
Neal Morton covers education and general assignments for The Monitor. He can be reached at (956)683-4472.
Many would be surprised at the competitive nature of the hospice industry. Agencies want a high census of patients fitting into a neat package of 6 months or less of life and cost effective care that makes the patient comfortable and the families as well.
When I started marketing hospice 7 years ago, I remember learning everything I could and would still find myself lacking confidence talking to doctors and nurses about referring to hospice. I found the same old tricks used by other marketers being used by hospice marketers. For example,
Cancer patients who have dis-enrolled from hospice services are more likely to go to the emergency room or remain longer in the hospital than
Good article on
http://www.aarp.org/relationships/family/info-09-2010/elder_mediation.html
Maybe we can help more families assist with “staying” family with stronger education. Mediation – new buzz word?
Internist Nesli Basgoz examines patient Barry Arcangeli who has a leaky heart valve. Basgoz discovered Arcangeli’s heart condition during a routine physical examination.
Internist Nesli Basgoz examines patient Barry Arcangeli who has a leaky heart valve. Basgoz discovered Arcangeli’s heart condition during a routine physical examination.
For centuries, doctors diagnosed illness using their own senses, by poking, prodding, looking, listening. From these observations, a skilled doctor can make amazingly accurate inferences about what ails the patient.
Technology has changed that. “We’re now often doing expensive tests, where in the past a physical exam would have given you the same information,” says Jason Wasfy, a cardiologist-in-training at Massachusetts General Hospital in Boston.
As a result, many doctors are abbreviating the time-honored physical exam — or even skipping it altogether.
Some Patients Never Examined
“It’s amazing to me that in this day and age there are some patients who go to their doctor, and the doctor doesn’t even examine them,” says Roman DeSanctis, a senior cardiologist at Massachusetts General Hospital who is famous for his diagnostic skills.
“I sometimes joke that if you come to our hospital missing a finger, no one will believe you until we get a CAT scan, an MRI and an orthopedic consult. We just don’t trust our senses.”
- Dr. Abraham Verghese
DeSanctis says he recently listened to one patient’s chest and heard the unmistakable sounds of abnormal fluid buildup. It turned out he had lung cancer.
“I said, ‘Did Dr. So-and-so mention anything about this when he saw you?’ ” DeSanctis says. “And he said, ‘Well, he took my blood pressure, but he didn’t really examine me.’ This is not an isolated case.”
And it appears that the trend is likely to get worse. “I’m definitely worried that the physical exam is dying a slow death,” says Nesli Basgoz, a physician at Massachusetts General Hospital.
She reports that young trainees often ask her why they need to learn the subtle and hard-won skills needed to do a good physical exam.
“They say, ‘If it’s so important, how come we sit around in a conference room and talk about what’s in the chart, instead of spending more time seeing patients?’ ” Basgoz says.
Basgoz is trying to buck the trend — in her teaching and by setting a good example.
Careful Exam Crucial
To illustrate how important a thorough physical can be, she introduces patient Barry Arcangeli, a 50-year-old man with a leaky aortic valve.
Arcangeli’s heart murmur “is loud and it’s long,” Basgoz says, offering the patient and a visitor the chance to listen for themselves. “Do you hear it?” she says. “It goes ‘whooo-whooo.’ That ‘whooo’ sound shouldn’t be there at all.”
Arcangeli has no heart symptoms, so his leaky valve would probably not have been picked up if Basgoz hadn’t noticed it during a routine physical exam. She says at some point he’ll probably need a new heart valve, but meanwhile he needs careful monitoring and preventive treatment.
Even when doctors go through the motions of doing a physical, their diagnostic skills aren’t what they used to be. One recent study in the Journal of the American Medical Association examined stethoscope skills of various kinds among 453 practicing physicians and 88 medical students. Whatever their age or experience, the doctors correctly recognized only 20 percent of heart problems.
At Stanford Medical School, professor Abraham Verghese is leading the charge to restore the physical exam to what he considers its rightful place, and bring doctors’ skill up to snuff.
“I sometimes joke that if you come to our hospital missing a finger, no one will believe you until we get a CAT scan, an MRI and an orthopedic consult,” Verghese says. “We just don’t trust our senses.”
Verghese says it’s as though the output of machines is the only information that counts.
“You know, we often spend so much time with that entity in the computer — I call it the ‘iPatient,’ like your iPad and your iPhone. And the real patient in the bed is often left wondering, ‘Where is everybody? What are they doing?’ I sense that we’re spending very little time at the bedside.”
Stanford 25
Stanford Medical School in California is trying to make sure its graduates and trainees know how to do 25 bedside tests that it considers essential to good doctoring.
Here’s the list:
- Examine the back of the eye
- Examine the pupil of the eye and its response to light
- Examine the thyroid gland
- Examine the neck veins for abnormal size and pulses
- Examine the lung’s surface, lung sounds and borders
- Evaluate the heart’s motion
- Examine the liver’s size and shape
- Evaluate the spleen’s size and density
- Evaluate gait (walking movements)
- Test ankle reflexes for nerve abnormalities
- Identify markers of liver disease throughout the body
- Identify signs of stroke caused by blockage of a deep brain artery
- Examine the knee
- Identify abnormal heart sounds
- Evaluate tremors and other involuntary movements
- Recognize markers of disease in the hands and fingernails
- Examine the tongue
- Examine the shoulder for injuries and joint abnormalities
- Assess blood pressure and abnormal pulses
- Assess lymph nodes in the neck
- Detect fluid in the abdomen and abdominal blood flow
- Perform a rectal exam
- Evaluate a mass in the scrotum
- Test balance and ability to perceive the body’s position in space
- Use a pocket ultrasound device*
*This item is not yet standard practice in most U.S. medical settings, but Dr. Abraham Verghese of Stanford hopes it will be. He says it’s valuable in detecting abnormal fluids, quickly evaluating heart function and assessing organ abnormalities
–Richard Knox
Reversing The Trend
At Stanford, they’re trying to reverse the trend. The school’s graduates and trainees have to master 25 different bedside exam skills, from palpating a spleen to testing ankle reflexes. (See accompanying sidebar)
Verghese is convinced that doctors who know how to do a competent physical will pick up a lot of serious problems. “My worst nightmare,” he says, “is that someone passes through my hands with a diagnosable, treatable condition that I missed because of sloppy technique. And they pop up six months later with somebody else at a point when it’s not treatable.”
But some critics consider Verghese an incurable romantic.
“I don’t believe that trying to resurrect the physical exam of yore is the right use of the increasingly scarce time we have with our trainees,” says Bob Wachter, a professor and chief of the Division of Hospital Medicine at the University of California, San Francisco. “And some of the time the physical exam doesn’t stand up very well against some of the other tests that we have. It’s just not accurate enough.”
Wachter says it’s more important to spend the time talking to the patient and answering questions than percussing, palpating, peering into eyes and ears, tapping on knees and doing all of the other things in the classic physical.
But Verghese says there’s another important reason to do physical diagnosis: Patients miss the laying on of hands.
The Importance Of Touch
“I always listen to language very carefully when people complain about us –- and they complain a lot,” the Stanford internist says. “And if you listen to the words people use, it’s very often, ‘He or she never laid a hand on me, he or she never touched me, he or she was hardly listening and they were busy entering stuff into the computer.’ “
Verghese says before doctors dispense with the physical exam they should think about what’s really happening during the encounter.
“If you look at the physician exam –- one individual coming to another, telling them things they would not tell their spouse or rabbi or priests, and then, incredibly, disrobing and allowing touch,” Verghese says. “I think our skills in examining a patient have to be worthy of that kind of trust.”
And the full ritual is necessary, he says, to establish that connection.
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I believe just the touch can often make a difference, and the optimal treatment begins with instinct by the doctor and the patient.
Volunteer Training Online
Those who have started the course in the past couple of years have agreed that it is a great start to their venture into palliative care
I ran across an article this morning that I found a few months ago.
Like a memorable song, the content plays in your head and you forget it. Later when it reappears you remember what a great song it was. So it was with this article.
Donald P. Copley, M.D., a cardiologist wrote about the benefits
Adding HIPAA information to the volunteer training program has proved quite daunting.
I have researched the OCR and HHS sites and
See more news releases in: Health Care & Hospitals, Awards, Senior Citizens, Domestic Policy
Hospice Volunteer Awards Presented at National Conference in AtlantaAwards Sponsored by National Hospice Foundation and the National Hospice and Palliative Care Organization
ALEXANDRIA, Va., Sept. 14 /PRNewswire-USNewswire/ — There are more than 550,000 trained, hospice volunteers contributing more than 25 million hours annually to hospice organizations across the country. Three of those volunteers were honored by the National Hospice and Palliative Care Organization and the National Hospice Foundation for their extraordinary efforts to serve.
The Volunteers are the Foundation of Hospice Awards were presented today at NHPCO’s 11th Clinical Team Conference at the Sidney Marcus Auditorium at the Georgia World Congress Center in Atlanta.
“One of the highlights of my job is meeting the staff and volunteers working in hospices across the country. Each and every hospice volunteer deserves recognition and the highest of accolades but the volunteers we are recognizing today truly demonstrate an outstanding level of commitment and passion,” said Donald Schumacher, president and CEO of NHPCO and the National Hospice Foundation.
The Volunteers are the Foundation of Hospice Awards, created and administered by NHPCOs NATIONAL COUNCIL OF HOSPICE AND PALLIATIVE PROFESSIONALS, recognize hospice volunteers who best reflect the universal concept of volunteerism in its truest sense—serving as an inspiration to others. The 2010 awards were presented to volunteers whose work has focused on specific areas.
- Patient/Family Support: Margaret Williams-DeCelles, a volunteer with Partners Hospice in Waltham, Massachusetts.
- Organizational Support: Charlotte “Jeff” Liddell, a volunteer with Hospice of Lancaster County, Pennsylvania.
- Teen Service: Juno Lee, a volunteer with Suncoast Hospice in Clearwater, Florida.
Schumacher added, “The service of volunteers — in every aspect of hospice and palliative care — is truly a gift of caring that makes a world of difference to patients, families and the organization’s they serve.”
Learn more about these distinguished award recipients in the awards section of NHPCO’s website at www.nhpco.org/awards.
NHPCO is the oldest and largest nonprofit membership organization representing hospice and palliative care programs and professionals in the United States. NHPCO’s mission is to lead and mobilize social change for improved care at the end of life.
SOURCE National Hospice and Palliative Care Organization
RELATED LINKS
http://www.nhpco.org
Congratulations to the cream of the elite crop. You are a light to those lost in their own darkness.
Topics: Aging, Medicare, Health Reform
By Michelle Andrews Sep 07, 2010 About this time last year, voters and politicians were consumed by the rumor, fanned by health-care overhaul opponents, that the legislation would include “death panels” of government bureaucrats who could “pull the plug on Grandma” if she needed costly care.
The outcry led legislators to scrap a provision of the House bill that would have paid for voluntary consultations between physicians and Medicare beneficiaries about end-of-life care: living wills, hospice benefits and the like. More From This Series: Insuring Your Health
Since the furor died down, end-of-life care has been mostly out of the spotlight. But misperceptions remain. A July poll by the Kaiser Family Foundation found that 36 percent of seniors still believe that the overhaul creates “death panels.” Another 17 percent said they didn’t know one way or the other.
Many people may not realize that, in some ways, the new law will expand options for patients at the end of life.
One of these involves hospice care, in which a team of specially trained providers treats dying patients’ pain and other symptoms but doesn’t try to cure the underlying disease. The team also helps the patients’ families, instructing them in caring techniques and providing bereavement counseling after death. Under current Medicare rules, beneficiaries whose doctors determine that they have less than six months to live can choose hospice care — but only if they forgo any further life-prolonging treatment related to their disease.
The new law establishes a three-year “concurrent care” demonstration program at 15 sites nationwide, in which Medicare would cover both kinds of treatment simultaneously.
Although the vast majority of patients seeking hospice benefits are over 65, starting in 2013, the new law also allows children who are enrolled in Medicaid or the Children’s Health Insurance Program (CHIP) to receive both hospice and curative care.
Some private insurers, such as Aetna and UnitedHealthcare, have been offering concurrent care to their private-market clients for years.
Experts agree that hospice benefits can provide crucial support for both patients and families during a very difficult time, and some research indicates they may extend the patient’s life. Yet fewer than 40 percent of patients are in hospice care when they die, according to the National Hospice and Palliative Care Organization.
Many terminally ill patients wait until death is imminent to choose hospice care. The median length of time in hospice was just over 20 days in 2008; more than a third of people died or were discharged from hospice in seven days or less.
“We think it’s far too short a period for patients and their families to adjust to the realities of impending death,” says Jon Keyserling, vice president of public policy and counsel for the NHPCO.
Adding support to the notion that providing curative and supportive benefits together is good for patients is a study published last month in the New England Journal of Medicine. It found lung cancer patients who received specialized care to help manage their physical and psychosocial symptoms while they were undergoing standard cancer treatment received less aggressive end-of- life care but lived longer than patients who received standard cancer treatment alone.
After going through a couple of rounds of chemotherapy and many radiation treatments to treat his lung cancer, Crune Carawan finally decided he’d had enough. Somewhat reluctantly, his wife, Judith, who’d been caring for him since his diagnosis in May 2009, called a hospice center near their home in Columbus, Ohio. “I was skeptical about hospice,” she says.
She quickly changed her mind. Three hospice nurses came to the home, evaluated her husband and adjusted his medications, making sure he wasn’t in any pain. They ordered a hospital bed and got it set up that same day.
Over the course of the next week, a nurse visited several times to help calm him when he felt anxious. They also talked with her about what to expect and gave her a small book that described the changes she might see in him. He died seven days after their first visit.
“I kind of do wish they’d come in earlier,” Judith Caravan says. “He really enjoyed the nurses. They’d come in and laugh with him.”
Hospice professionals say patients and family members are better served if they use hospice benefits for about two months.
Experts agree that the requirement that they forgo curative treatment stops some Medicare patients from choosing hospice. Even when aggressive therapy may provide little therapeutic benefit while severely diminishing the patient’s quality of life, it’s not easy to say “no more.” Once the 15 demonstration sites are up and running, expected sometime in 2012, participants won’t have to make that choice. kff.org © 2010 Henry J. Kaiser Family Foundation. All rights reserved.