National Study Finds Further Evidence That Hospice Use Does 'Not

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Vol. 13, Issue 3 Nov/Dec/Jan 2011-2012 National Study Finds Further Evidence That Hospice Use Does ‘Not Compromise Survival’

Bolstering other recent findings that hospice care does not shorten — and may even prolong — survival among “Appropriate timing of referral to hospice gives terminally ill cancer patients with cancer, an international patients and their families more time and opportunity to benefit team of researchers reports that Medi- from palliative services and avoid futile interventions. Concern care hospice patients have a slight survival advantage over their nonhospice about hastening death should not be a barrier to hospice care.” counterparts. Further, aggressive care — Saito et al, Journal of Palliative Medicine delivered late in the illness is more likely merely to shorten hospice stay than to extend life. have comparable or even longer sur- KEY FINDINGS: “Despite a significant relationship vival compared to nonhospice patients, • Survival was found to favor hospice between aggressive care at the end of based on three different statistical ap- patients relative to nonhospice pa- life and no or only short-term hospice proaches,” write the authors of a re- tients by 5.0% at one year follow- stay, hospice patients were found to port published in the Journal of Pal- ing diagnosis (25.7%, hospice pa- liative Medicine. tients vs 20.7%, nonhospice) and by The team conducted multiple analy- 1.4% at two years post-diagnosis Inside: ses of data on Medicare patients (n = (6.9% vs 5.5%). NewsLine ...... 2-3 7879) who survived for at least three • Longer-term hospice patients had 3 Achieving Equitable Access to Quality months following diagnosis of non- longer survival than nonhospice Hospice and Palliative Care: We’re at small-cell lung cancer between 1991 the ‘Tipping Point,’ Declares Expert patients (hazard ratio [HR], 0.87; and 1999. Patients were divided into Research Monitor ...... 4-6 95% confidence interval [CI], 0.83 matched “hospice” and “nonhospice” to 0.91; p = 0.0001). 3 When Patients Have Multiple groups, with the hospice group further Comorbidities: The Challenges of • Short-term hospice patients had a End-of-Life Discussions without divided according to length of stay: similar, although slight, survival ad- One Clear Terminal Diagnosis “short term” (< 3 days in hospice) or 3 vantage compared with patients in Timely Receipt of Hospice Services “longer term” (> 4 days in hospice). Yields Higher Family Perceptions the nonhospice group (HR, 0.94; of Quality of Nursing Home Death Indicators of “aggressive care” near among Dementia Patients 95% CI, 0.83 to 1.05; p = 0.26). the end of life included: a new chemo- 3 New Accreditation Standards from the • Hospice patients with short-term ad- American College of Surgeons Focus on therapy regimen begun less than 30 missions were more likely to be male, Patient-Centered, Supportive Approach days before death; receiving a last dose to Hospice and Palliative Care urban dwellers, and to have received 3 Informing Patients of Impending Death of chemotherapy within 14 days of aggressive care near the end of life. Linked to Improved End-of-Life Care, death; more than one emergency de- with No Increase in Pain or Anxiety partment visit or hospital admission in OVERALL: Clinician Resources ...... 7 the last month of life; or being hospi- • 47.9% of all patients received hos- 3 Approach to Addressing Cultural talized for longer than 14 days in the Beliefs and Preferences pice care. final month. Continued on Page 3 NEWSLINE

Achieving Equitable Access to Quality Hospice and Palliative Care: We’re at the ‘Tipping Point,’ Declares Expert Caring for the sickest Medicare beneficiaries — the 10% with serious illness or multiple chronic conditions — ac- Policy Focus for Improving Access counts for 57% of the total program spending, yet studies to Quality Palliative Care demonstrate that these patients and their families are receiving health care of inadequate quality. The dual goals • Enhance the medical and nursing workforce with ex- of cutting expenditures and delivering the care that patients pertise in palliative care need and desire can be achieved by strengthening access • Invest in the field’s research evidence base to quality palliative care and hospice. • Increase availability of services in hospitals and nurs- That is according to an article published in the Septem- ing homes ber issue of The Milbank Quarterly, a peer-reviewed, — Meier, The Milbank Quarterly multidisciplinary journal of population health and health policy. The article reviews the benefits of palliative care and the barriers to its delivery, and suggests policy ap- clarity of the care plan, and consistent follow-through proaches for standardizing access to high-quality care. • Easing the burden experienced by families and in- “Palliative care and hospice services improve patient- creasing satisfaction by supporting families in routine centered outcomes such as pain, depression, and other care, in crisis, and in bereavement symptoms; patient and family satisfaction; and the re- COST SAVINGS OF PALLIATIVE CARE AND HOSPICE ceipt of care in the place that the patient chooses,” writes author Diane E. Meier, MD, professor of geriatrics and Recent data show that the average per-patient, per-ad- palliative medicine at the Mount Sinai School of Medi- mission, net cost saved by using hospital palliative care cine, New York City. consultation is $2659, which translates into an estimated “By helping patients get the care they need to avoid un- $1.2 billion saved per year by the programs currently es- necessary emergency department and hospital stays and tablished at more than 60% of U.S. hospitals. Meier points shifting the locus of care to the home or community, pallia- out that this figure could increase to $4 billion saved, if tive care and hospice reduce health care spending for appropriate hospital palliative care services were expanded America’s sickest and most costly patient populations.” to meet the needs of most patients who are currently dis- charged with serious and complex chronic illness without PALLIATIVE CARE AND HOSPICE TEAMS: benefit of these services. DELIVERING HIGH-QUALITY CARE Hospice care, currently provided to over 1.5 million pa- Much of the strength of palliative care services lies in tients yearly, has been shown to reduce total health care their coordinated, patient-centered, multidisciplinary ap- costs by an estimated $2300 per Medicare beneficiary, with proach. Palliative care and hospice teams improve quality an average annual savings of more than $3.5 billion per of care by: year. When patients disenroll from hospice, their medical • Identifying and rapidly treating distressing symptoms costs are nearly five times higher than for those who re- that are shown to increase medical complications and main in hospice care, Meier points out. hospitalization The United States is unique in its categorization of pal- • Planning for safe transitions from acute care to more sup- liative care into two distinct types, notes Meier, in that it portive settings, such as home health care, home or in- labels “palliative care” as needs-based, with no prognostic patient hospice, or nursing home care with hospice restriction, and “hospice” as palliative care that is restricted • Avoiding nonbeneficial or harmful tests, procedures, or to patients with a prognosis of living six months or less. specialty consultations The relatively new field of palliative care outside of hos- • Meeting often with patients and families to establish real- pice has been created largely by private sector contribu- istic goals, leading to better-informed decision making, Continued on Page 3

PAGE 2 QUALITY OF LIFE MATTERS NOV/DEC/JAN 2011-2012 NEWSLINE

National Study Finds Further Evidence That Hospice Use Does ‘Not Compromise Survival’

Continued from Page 1 cancer patients nearing death, the authors point out. “Ad- vances in medical technologies and a perception that pa- • 92.6% of the hospice patients died under hospice care, tients favor receiving aggressive care even very near death while only 2.8% died in a hospital. for small expected benefits may reduce the number of pa- • In contrast, 39.7% of nonhospice patients died in an acute tients referred to hospice,” they suggest. care setting. Nevertheless, the authors state firmly in their conclusion, • Hospice patients were older, more likely to be non-His- “[the] use of hospice and length of hospice stay for Medi- panic white and female, and more likely to live in urban care patients with advanced non-small-cell lung cancer did areas with high hospice availability. not compromise survival.” “[R]egional availability of hospice was associated with Source: “Hospice Care and Survival among Elderly Patients with Lung any hospice use, but not with length of hospice stay,” the Cancer,” Journal of Palliative Medicine; August 2011; 14(8):929-939. Saito AM, Landrum MB, Neville BA, Ayanian JZ, Weeks JC, Earle CC; authors point out. “Instead, experiencing aggressive end- Laboratory of Clinical, Epidemiological, and Health Services Research, of-life care was more predictive of shorter duration of hos- Clinical Research Center, National Hospital Organization Nagoya pice use.” Medical Center, Aichi, Japan; Department of Health Care Policy, Harvard Medical School, Boston; Division of Population Sciences, Department of Despite the results of recent studies showing that hos- Medical Oncology, Dana-Farber Cancer Institute, Boston; Division of General Medicine, Brigham and Women’s Hospital, Boston; Cancer Care pice care does not hasten death, there is a current trend in Ontario, Ontario Institute for Cancer Research, and the Institute for this country toward increasingly aggressive care among Clinical Evaluative Sciences, Toronto.

Achieving Equitable Access to Quality Hospice and Palliative Care: We’re at the ‘Tipping Point,’ Declares Expert Continued from Page 2 oped by the American Academy of Hospice and Pallia- tions and initiatives from major professional organizations. tive Medicine and the Center to Advance Palliative Care, Meanwhile, the growth in federally mandated hospice respectively. programs has resulted in a national workforce that is “Ensuring access to high-quality palliative care for already trained and experienced in caring for this high- all Americans who might benefit requires that provid- need population. Meier suggests combining the strengths ers be trained to deliver this kind of care; that an evi- of these services. dence base exists to ensure quality; that health care “Linking palliative care and hospice teams to imple- organizations have the capacity to provide palliative menting new delivery models may increase the likeli- care; and that the public understands what palliative hood of their achieving their quality and health care value care and hospice are and demand such care from their objective,” suggests Meier. “The combined and sustained clinician,” declares Meier. commitment of both the private and the public sectors “We have come a long way toward achieving these will be necessary to bring the palliative care innovation goals, and ensuring that palliative care is reliably avail- to scale in the United States.” able to America’s sickest and most vulnerable patients Meanwhile, Meier suggests that organizations and cli- and their families is now at a tipping point.” nicians can help increase public awareness and access Source: “Increased Access to Palliative Care and Hospice Services: to palliative care and hospice services by directing con- Opportunities to Improve Value in Health Care,” The Milbank Quarterly; September 2011; 89(3):343-380. DOI: 10.1111/j.1468-0009.2011.00632.x. sumers, employees, and patients to such websites as Meier DE; Department of Geriatrics and Palliative Medicine, Mount Sinai palliativedoctors.org and getpalliativecare.org, devel- School of Medicine, New York City.

NOV/DEC/JAN 2011-2012 QUALITY OF LIFE MATTERS PAGE 3 RESEARCH MONITOR

When Patients Have Multiple Comorbidities: The Challenges of End-of-Life Discussions without One Clear Terminal Diagnosis

Prognostic uncertainty and lack of good While less than half had participated in perceived readiness to initiate such a dis- communication tools are two major barri- EOL discussions with a patient with mul- cussion. ers to conducting effective end-of-life tiple morbidities in a clinical setting, more (EOL) conversations for timely referral to than 80% had engaged in such discussions APPROACHESTO DISCUSSION palliative and/or hospice care. When eld- in private life. Participants identified three types of ap- erly patients have a variety of chronic dis- Participants overwhelmingly reported proaches to discussing EOL care with pa- eases, deciding when and how to conduct that EOL discussions are more challeng- tients with multiple comorbidities: such conversations may be uniquely chal- ing with multimorbid patients. Physicians In the direct approach, the physician lenging, according to a report published believed that a terminal diagnosis such as introduces the topic after assessing the in the American Journal of Hospice & cancer was easier and less time-consum- patient’s readiness and receptiveness. Al- Palliative Medicine. ing for physicians to explain, easier for though difficult, this physician-driven ap- “These difficulties may be magnified in patients/families to understand and accept, proach may be needed when families hesi- patients with multimorbid medical condi- and thus it was easier to reach a consensus tate because of feelings of guilt. tions — often characterized as ‘debility, regarding prognosis and a plan of care. The second method, the indirect ap- unspecified’ — where both the timing and “Cancer appears to be a special case, in proach, was considered to be more effec- content of conversations about EOL issues that patients and families seem to under- tive. The physician encourages the patient/ may pose difficulties for providers,” write stand that cancer is often terminal, while family to broach the topic, by using an the authors. “For these patients, there is on the other hand, patients and families open-ended question such as asking how no single, clear ‘terminal’ diagnosis that seem to believe that other diseases with they think the patient is doing. precipitates the transition to EOL care, nor comparable life expectancies (e.g., heart The third option is the collaborative is there often a sentinel event that signals a failure or renal disease) can be treated or approach, in which the physician calls for marked and clear decline.” cured,” the authors point out. a structured family meeting, provides in- A review of the literature finds that there Another important difference is that formation for all involved to discuss, then are knowledge gaps regarding what prog- “with a clear, terminal diagnosis, provid- ends the meeting by making sure clear de- nostic tools or communication scripts ers and patients focus on the diagnosis it- cisions have been agreed upon. might assist physicians with predictive ac- self, whereas with multiple comorbidities, “[F]uture research is needed to deter- curacy and timing of discussions for the focus tends to be more on the quality mine ways to overcome both the real and multimorbid patients, the authors point out. of life of the patient,” the authors add. perceived barriers to having EOL conver- Many of these patients exhibit debility, sations with older patients with multiple TIMING THE EOL DISCUSSION frailty, or failure to thrive, yet none of these comorbidities and their families,” conclude WITH MULTIMORBID PATIENTS diagnoses clearly indicates a terminal con- the authors. “Facilitating effective com- dition. Nevertheless, “these patients are Physicians in the study reported a num- munication and optimal times for this pa- dying, and ensuring appropriate EOL ber of physical cues they use to prompt tient population may better respect patient care planning requires that both health discussions, such as health status, fre- autonomy, improve overall quality of life, care providers and patients and their quency of visits, efficacy of treatment, and enhance provider-patient relationships.” families address this fact,” they note. decreased functional status, or age. “Par- Source: “Assessing Challenges in End-of-Life ticipants were unaware of the existence of Conversations with Elderly Patients with Multiple PHYSICIAN EXPERIENCES: prognostic tools to aid them in estimating Morbidities,” American Journal of Hospice & A QUALITATIVE STUDY Palliative Medicine; Epub ahead of print, August a multimorbid patient’s prognosis, but were 25, 2011; DOI; 10.1177/1049909111418778. The team analyzed qualitative data gath- interested in learning more.” Schonfeld TL, Stevens EA, Lampman MM, Lyons WL; Bioethics Program, Center for Ethics, and ered from focus groups consisting of a to- Social cues that can prompt EOL con- Department of Medicine, School of Medicine, tal of 32 attending or resident physicians versations included the establishment of a Emory University, Atlanta, Georgia; Department (mean age, 37.8 years; female, 59.4%) in rapport with the patient, statements of pa- of Health Management and Policy, University of Iowa, Iowa City; and Department of Internal family, internal, or geriatric medicine at a tient readiness, patient remarks about qual- Medicine, College of Medicine, University of Midwestern academic medical center. ity of life, or even the physician’s own self- Nebraska Medical Center, Omaha.

PAGE 4 QUALITY OF LIFE MATTERS NOV/DEC/JAN 2011-2012 RESEARCH MONITOR

Timely Receipt of Hospice Services Yields Higher Family Perceptions of Quality of Nursing Home Death among Dementia Patients

Family members of nursing home resi- fective symptom management and maxi- five states (AL, FL, MA, MN, and TX). dents with dementia who died while un- mization of quality of life, hospice ser- der hospice care were twice as likely as vices should be of significant benefit to KEY FINDINGS: those whose loved ones did not receive nursing home residents, yet little research • Overall, 73.2% of dementia patients died hospice to give high ratings for the quality has examined the effectiveness of hospice in the nursing home. of care received, researchers have found. services for persons dying of dementia,” • Family members of those receiving hos- Further, ratings of care were even higher the authors maintain. pice care were 51% less likely to report when families believed that hospice ser- Investigators compared responses re- unmet needs and concerns with quality vices were instituted in a timely manner. garding the quality of care and quality of of care than were respondents whose “This is the first study that provides dying reported by 538 bereaved family loved ones were not in hospice (adjusted evidence that the provision of hospice members of hospice and nonhospice nurs- odds ratio [AOR], 0.49; 95% confi- services, especially when they are initi- ing home decedents who had dementia as dence interval [CI], 0.33 to 0.74). ated ‘at the right time’ for persons with the listed cause of death. Results were fur- dementia, improve family members’ ther stratified based on whether family • Compared with respondents whose loved perceptions of the quality of care,” write members felt their loved ones had received ones died without hospice care, family the authors of a report published in the hospice services “too late” or “at the right members of hospice patients were twice Journal of the American Geriatrics Society. time.” The mortality follow-back survey as likely to give high ratings for the Since the goals of hospice care are “ef- was conducted between 2007 and 2009 in Continued on Page 6

New Accreditation Standards from the American College of Surgeons Focus on Patient-Centered Approach to Hospice and Palliative Care

A patient-centered approach to cancer facilities throughout the diagnosis and would not be surprising” care is now a required part of the accredi- treatment process, the updated standards “Cancer care over the last 50 years has tation standards set for hospital cancer pro- emphasize the importance of a supportive, evolved from its primary focus on local grams by the Commission on Cancer of patient-centered approach to care. disease to a sophisticated, multidiscip- the American College of Surgeons (ACS), linary approach...,” states the manual. ACCREDITED PROGRAMS ARE which just released its new manual entitled, “Unfortunately, there remains substan- REQUIREDTO OFFER: “Cancer Program Standards 2012: Ensur- tial evidence that many people with can- ing Patient-Centered Care.” • Screening for psychosocial distress and cer do not receive the benefits of high “The changing landscape of cancer pa- access to support for patients and quality care that are now possible. Meet- tient care motivated us to develop new stan- families ing these standards is the obligation of dards to directly address patient concerns,” • Care for cancer-related pain all who provide cancer care.” says commission chair Stephen B. Edge, • A patient navigation process to help The multidisciplinary commission is MD, professor of surgery at the School of coordinate multidisciplinary care and a consortium of 47 professional organi- Medicine and Biomedical Sciences, State facilitate timely access to quality zations that establishes cancer care stan- University of New York at Buffalo. “These medical and psychosocial care dards and monitors quality at the more standards enhance the focus of care so that than 1500 hospitals it accredits. Accord- it is much more than a defined structure • Palliative care (either on-site or by re- ing to the ACS, these institutions repre- of clinical treatment.” ferral to other locations, including com- sent more than 70% of all new cancer While ensuring that key elements of munity-based resources) cases diagnosed annually. quality cancer care are provided to every • Access to hospice care when prog- For more information, visit www.facs.org/ patient treated at one of their accredited nosis is limited and when “death cancer/coc/programstandards2012.html.

NOV/DEC/JAN 2011-2012 QUALITY OF LIFE MATTERS PAGE 5 RESEARCH MONITOR

Informing Patients of Impending Death Linked to Improved End-of-Life Care, with No Increase in Pain or Anxiety Being informed of the imminence of tients who died of advanced cancer had higher rate of relief among informed death does not lead to more unrelieved documentation regarding the imminence patients. symptoms among cancer patients during of their expected deaths and whether or • Staff knowledge of the patient’s pre- the last week of life, but rather appears to not they had been so informed. Since only ferred place of death was significantly increase the probability that patients will 9% of patients had not been informed, re- higher among informed patients than receive needed symptom control and die searchers compared two matched groups among those who were uninformed in the location of their choice, a team of (informed vs uninformed) consisting of (75% vs 41%). Swedish researchers has found. 1191 patients in each group. “To give information about imminent “Providing information of imminent KEY FINDINGS: death is a conscious act that involves death to a patient with cancer at the end of awareness of the fact that the patient is life does not seem to increase pain or anxi- • Significantly more patients in the in- dying, an awareness that also implies ety, but it does seem to be associated with formed group than in the unin- preparedness of the health care profes- improved care and to increase the likeli- formed group died in their preferred sional,” comment the authors. “Such pre- hood of fulfilling the principles of a good location (70% vs 39%). paredness should increase the probability death,” write the authors of a report pub- • Patients in the informed group were of a more proactive approach with respect lished in the Journal of Clinical Oncology. more likely to have parenteral as-needed to prescribing palliative drugs and address- The team analyzed data collected on all prescriptions, and to have their family ing patient and family wishes and needs cancer deaths between 2006 and 2008 from members informed and offered bereave- during the last days of life (i.e., a concept the Swedish Register for Palliative Care. ment support. of total care).” This national quality register is an online • Registered symptoms (pain, anxiety, Source: “Information of Imminent Death or Not: questionnaire based on the 11 principles confusion, nausea, dyspnea, and respi- Does It Make a Difference?” Journal of Clinical of a good death as defined by the British Oncology; Epub ahead of print, September 12, ratory tract secretions) were reported as 2011; DOI: 10.1200/JCO.2011.34.6247. Geriatrics Society, and is completed by being relieved in 80% to 96% of all pa- Lundquist G, Rasmussen BH, Axelsson B; Umeå the physician and/or nurse who cared for tients. There were no significant differ- University and Umeå Hospice, Umeå; Center of Clinical Research, County Council of Dalarna, the patient during the last week of life. ences between the two groups, except Falun; and Östersund Hospital, Östersund, During the study period, 13,818 pa- for confusion, which had a slightly Sweden.

Timely Receipt of Hospice Services Yields Higher Family Perceptions of Quality of Nursing Home Death among Dementia Patients Continued from Page 5 cerns with the quality of care, and higher also whether the family member believes quality of care (AOR, 2.0; 95% CI, 1.53 family ratings of the quality of care,” write that they received hospice services in a to 2.72). the authors. “Additionally, family mem- timely manner that is an important • Among family members who reported bers reported that decedents who received quality concern.” that hospice services were timely, the hospice services had better quality of dy- Source: “Does Hospice Improve Quality of Care likelihood of high ratings for quality of ing than those who did not receive hos- for Persons Dying from Dementia?” Journal of the American Geriatrics Society; August 2011; care was even greater (AOR, 2.30; 95% pice services.” 59(8):1531-1536. Teno JM, Gozalo PL, Lee IC, CI, 1.69 to 3.13). Although few survey respondents re- Kuo S, Spence C, Connor SR, Casarett DJ; • Quality of death was more likely to be ported that residents were referred to hos- Department of Community Health, Warren Alpert School of Medicine, Brown University, rated highly by respondents whose loved pice services too late (n = 33), the “find- Providence, Rhode Island; National Hospice and ones died under hospice care (AOR, ings show that time of referral to hospice Palliative Care Organization, Alexandria, Virginia; 1.68; 95% CI, 1.11 to 2.56). services is related to perceived quality of Worldwide Palliative Care Alliance, London, United Kingdom; and Division of Geriatrics, School “Hospice services were associated with care,” note the authors. “Therefore, it is of Medicine, Department of Medicine, University fewer unmet needs, fewer reported con- not only receipt of hospice services, but of Pennsylvania, Philadelphia.

PAGE 6 QUALITY OF LIFE MATTERS NOV/DEC/JAN 2011-2012 CLINICIAN RESOURCES

Approach to Addressing Cultural End-of-Life Care Websites Beliefs and Preferences www.aahpm.org Misunderstandings can arise in communication about serious ill- American Academy of Hospice ness and palliative care due to patients’ particular cultural beliefs and Palliative Medicine held regarding the end of life. A recent monograph from EPERC (End-of-Life/Palliative Education Resource Center) outlines ap- www.eperc.mcw.edu End-of-Life/Palliative Education proaches for avoiding miscommunication with these patients and Resource Center (EPERC) their families. University of Pittsburgh Medical Center experts offer the follow- www.epec.net ing suggestions in EPERC’s Fast Facts and Concepts #216: The EPEC Project (Education in Palliative and End-of-Life Care) • Determine the patient’s information preferences, how and whether he or she wants medical information shared, and with whom. “Some www.nhpco.org people want to know everything about their medical condition, while National Hospice & Palliative Care Organization others do not. How much would you like to know?” Identify the patient’s main contacts, and how they choose to be informed.“Would you like www.caringinfo.org me to talk to your family alone, or would you like to be present?” Caring Connections: National Consumer • Respectfully explore the patient and family’s heritage and cultural Engagement Initiative to Improve End-of-Life Care values, using open-ended questions. “Is there anything about how you and your family view serious illness that would be helpful for me www.promotingexcellence.org to know?” If discussing death is acceptable, ask if there are concerns Promoting Excellence in about dying. “Are there things that are important to you that I should End-of-Life Care know about?” www.hospicefoundation.org • Communicate specific customs the patient wishes to be followed to Hospice Foundation of America the care team. The clinician may need to advocate for the patient to ensure — particularly in a hospital setting — that these will be hon- www.americanhospice.org ored. “Are there specific practices that you would like to have in the American Hospice Foundation hospital or at home? Are there aspects of medical care that you wish www.hpna.org to forgo or have withheld because of your cultural beliefs?” Hospice and Palliative Nurses • Identify the decision-making structure, and whether it includes the Association family and/or a community leader. “Do you prefer to make medical www.medicaring.org decisions about tests and treatments yourself, or would you prefer Palliative Care Policy Center that others in your family or community make them for you?” • Confirm the patient’s understanding by asking him or her to sum- www.abcd-caring.org marize what both of you have said. “Can you tell me, in your own Americans for Better Care of the Dying words, what you have heard from me and what is the most important www.mcw.edu/palliativecare.htm to you about what I have said?” Medical College of Wisconsin • Utilize the services of a medical interpreter, if there is a serious lan- Palliative Care Center guage barrier. www.painpolicy.wisc.edu • Determine whether the patient is open to receiving care in his or University of Wisconsin Pain her home when referring to hospice. This is important since most and Policy Studies Group hospice care is delivered in the home and some patients may be resis- tant to accepting help in the home from health care professionals out- www.capc.org Center to Advance Palliative Care side their cultural community.

Source: “Asking about Cultural Beliefs in Palliative Care,” Fast Facts and Concepts #216. www.stoppain.org Lum H, Arnold R; University of Pittsburgh Medical Center, Pittsburgh. Available at: Pain Medicine & Palliative Care, www.eperc.mcw.edu/fastfact/ff_216.htm. Beth Israel Medical Center

NOV/DEC/JAN 2011-2012 QUALITY OF LIFE MATTERS PAGE 7 Quality of Life Matters®

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