Hospice enrollment and hospitalization of dying nursing home patients.

PURPOSE: This study's purpose was to evaluate whether Medicare hospice care provided in nursing homes is associated with lower hospitalization rates. SUBJECTS AND METHODS: This retrospective cohort study included nursing home residents in five states who enrolled in hospice between 1992 and 1996 (n = 9202), and who died before 1998. For each hospice patient, 3 nonhospice residents (2 in 106 instances) were chosen (n = 27,500). Medicare claims identified hospice enrollment and acute care hospitalizations. RESULTS: Twenty-four percent of hospice and 44% of nonhospice residents were hospitalized in the last 30 days of life. Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (odds ratio 0.43; 95% confidence interval [CI]: 0.39 to 0.46). Considering all of nonhospice residents who died (n = 226,469), those in facilities with no hospice had a 47% hospitalization rate, whereas rates were 41% in facilities with low hospice use and 39% in facilities with moderate hospice use (5%+ of patients in hospice). Hospitalization was less likely for nonhospice residents in facilities with low hospice use (odds ratio 0.82; 95% CI: 0.80 to 0.84) and moderate hospice use (odds ratio 0.71; 95% CI: 0.69 to 0.74), compared with those in facilities with no hospice. CONCLUSIONS: When integrated into the nursing home care processes, hospice care is associated with less hospitalization for Medicare hospice patients. Additionally, possibly through diffusion of palliative care philosophy and practices, nonhospice residents who died in nursing homes having a hospice presence had lower rates of end-of-life hospitalizations.     

Ritual and dying: a cultural analysis of social support for caregivers

This study examines the role of social support in the process of caring for someone dying at home. Based on data from in-depth ethnographic interviews with 16 caregivers, it employs a cultural analysis to draw parallels with rituals of transition. Ritual provides a broad context of meanings and routines for securing the doubts and unknowns of individual experience. The way social support is provided plays a key role in the caregiver's transition to bereavement.     

Experience of dying: concerns of dying patients and of carers

Background: Terminally ill patients frequently express concerns about what dying will be like: how their bodies may change as disease progresses, how medication may alter the effect of these changes and whether and how their preferences will be respected as they become more ill. Methods: Thirty‐six patients admitted to a hospice were interviewed and 18 carers of patients of the Palliative Care service, who had died participated in focus groups. Thirty‐three patients had advanced malignant disease, 13 were women; their mean age was 68 years (range 44–92 years). Results: The areas of concern consistently identified by patients were (i) privacy and autonomy, principally in regard to families, (ii) a lack of information about physical changes and medication use as death approached and (iii) the desire to shorten life, which was expressed by all patients. Carers recalled problems accessing services and support and had needed more help with practical issues such as medication timing and dose. They believed that not enough information about the patients’ illnesses had been given to them and they were insistent that carers should have information against the wishes of patients. Conclusion: Some of the patients’ and carers’ concerns can be readily addressed. Others, particularly access to confidential information, cannot be addressed without a realignment of professional ethical standards and community expectations. The patients’ discussions of their desire to shorten life may have implications for the debate on euthanasia and physician‐assisted suicide.     

Clearinghouse: death and dying

Materials that deal with the issue of death and dying, bereavement, and hospice care are listed. The citations include books, journal articles, and supplements. Contact names for organizations that deal with these issues are also provided.     

The Hospice Caregiver Assessment: a study of a case management tool for professional assistance

A Hospice Caregiver Assessment Inventory was developed to identify the problems of those caring for dying patients. A corresponding Caregiver Intervention Plan was developed from the inventory data and utilized by agency professionals. Findings revealed the problems of caregivers of dying older persons and suggested that they often need counseling and assistance prior to the death of their loved one, as well as following death.     

Between a rock and a hard place: Orbital atherectomy for under-expanded stents

• Stent under-expansion (rather than intimal hyperplasia) may be the cause of in-stent restenosis.
• Later expansion of coronary stents that were not fully deployed initially, can be difficult.
• Atherectomy is one method of facilitating late stent expansion, but too few patients have been treated to determine the risk benefit ratio.

     

Caring for people who are dying on renal wards: a retrospective study

Unfortunately, there is still a high mortality rate among patients with end-stage renal disease (ESRD). If the decision is made to activate non-dialytic management of the patient with ESRD, it should be made jointly by the patient and responsible consultant nephrologist after consultation with relatives, the family doctor and other relevant members of the caring team. This paper discusses the establishment of a new renal supportive care service for patients opting not to have dialysis and focuses on the results of a 'death audit' carried out on this patient population. Recommendations for practice resulting from analysis of the audit results include, the use of advance directives, identification and prompt treatment of symptoms, increased staff education, timely referral to the palliative care team and expansion and further integration of the renal supportive care team.     

临终关怀与和缓医疗

临终关怀与和缓医疗是以预期生命有限的患者及其家庭成员为中心,通过预测、预防和治疗患者的病痛,改善其生活质量.主要内容是对症状进行评估和处理、控制疼痛、进行家庭护理、减轻或消除患者的心理负担和消极情绪,帮助临终患者以舒适和有尊严的方式度过最后的时光.临终关怀不同于安乐死,即不促进也不延缓患者的死亡,而是贯穿于疾病治疗始终,重视患者生理、智力、情感、社会及精神需求,帮助患者保持自主性、获取信息并自主选择.和缓医疗是现代医学领域中新的边缘交叉性学科,是人口老龄化的需求和人类文明发展的标志;和缓医疗需要一个多学科的团队,需要良好的沟通技巧和专业技能.