Should we screen hospice inpatients for orthostatic hypotension?

Orthostatic hypotension (OH) is defined as a reduction in systolic blood pressure of at least 20 mm Hg or a reduction in diastolic blood pressure of at least 10 mm Hg within three minutes of standing, with a reported prevalence of 40% in the hospice setting. Dizziness, falls and fractures have been attributed to OH and some cases of symptomatic OH might be reversible. This study explored the case for screening hospice inpatients for OH. Fifty-nine patients were screened up to five times and, whilst the detection rate was 27%, in no case was it reproducible. There was no statistical association between orthostatic symptoms and the detection of OH, and no patients benefited from the screening process. On closer examination of the literature, the current definition of OH might benefit from revision, sphygmomanometry is an unsatisfactory screening method and there is currently no case for screening hospice inpatients for OH.     

Primary thromboprophylaxis for hospice inpatients: who needs it?

Primary thromboprophylaxis (PTP) is a Department of Health priority in England. The NICE guidelines agree that PTP is inappropriate in the dying patient, but should be considered for those with reversible pathology. In the light of continued variation and uncertainty in UK hospice practice, we assessed PTP prescribing in three hospices. Case notes were reviewed from consecutive patients admitted before (300 patients) and after (350 patients) implementation of the Pan Birmingham Cancer Network (PBCN) venous thromboembolism prophylaxis (VTE) prevention guidelines. Just under half (43%; 40%) of patients had a contraindication to anticoagulation and PTP. Whilst just under a tenth (8.6%; 8.7%) in each group had a temporary increased risk of VTE, considerably fewer (3.6%; 6.3%) had a temporary increased risk of VTE without contraindication to PTP. Patients receiving PTP increased slightly from 1% to 3.6% and documentation of PTP decisions increased from 5% to 81%. Whilst the PBCN VTE tool is a useful tool to tailor an approach for this complex patient group, many questions remain. Clinical trials that include patients with advanced disease with relevant outcome measures are needed to help inform the clinicians who care for them.     

The moment of death: is hospice making a difference?

The moment of death was a compelling image and dominant concept through much of history. In recent years this term has become destabilized by technological advances and changes in clinical practice. Perhaps even more significantly, the meanings previously associated with the death-bed scene and the final breath have become increasingly marginalized. Hospice programs continue to demonstrate that enlightened and dedicated care can markedly reduce the suffering of terminally ill people and their families. The vast experience acquired by hospice programs, however, has not yet been translated into a vision of the moment of death and the death-bed scene for our times. Several reasons are identified for the limited interest and even more limited hospice-based research into the death-bed scene and the moment of death. Hospice programs could contribute much to our understanding of the final moments of life if this should ever become a priority.     

Community supply of hospice: does wealth play a role?

Context

Hospice is underused by older, rural, and minority populations.

Objective

Because local availability of hospice is an important predictor of use, we aimed to identify geographic variation in hospice supply and examine its community-level determinants, including wealth.

Methods

This was an observational geographic study using the 2008 National Hospice and Palliative Care Organization's National Data Set and the 2000 U.S. census data for 3140 U.S. counties. Our outcome of interest was hospice supply defined according to the number of hospice programs (regardless of level of care) servicing each county. We used binomial multivariable regression to test the relationship between supply and log-transformed counts of population, African Americans, Hispanics, residents aged 65, and high school educated residents as well as area, median household income, and certificate of need status.

Results

Hospice availability varied greatly across the United States, with an unadjusted mean of 24.3 hospice programs servicing each county (standard deviation 19.7, range 0-160). After adjusting for all covariates, median household income (incidence rate ratio [IRR] 1.03, P < 0.001), population count (IRR 17.9, P < 0.001), count of African Americans (IRR 1.26, P < 0.001) and elderly adults (IRR 2.81, P < 0.001) positively predicted supply, whereas area (IRR 0.84, P < 0.001), certificate of need status (IRR 0.89, P < 0.001), count of Hispanics (IRR 0.86, P < 0.01), and high school educated (IRR 0.03, P < 0.001) negatively predicted supply.

Conclusion

There is gross variation in hospice supply that can be explained by community wealth, population density, age, ethnicity, and race. To address disparate utilization of hospice, the relationship between wealth and availability will need to be better understood.     

Why hospice? The case for ESRD patients and their families

This article defines hospice by giving its historical context, its development over time, and its relevancy for the end stage renal disease (ESRD) patient. A literature review and explication of hospice usage statistics show the lack of utilization by the ESRD community. Comparison of hospice and traditional medical care highlights the philosophy of care over cure and hospice standards of practice are given. Medicare rules and two case studies support the appropriateness of hospice for ESRD patients and their families.     

The fundamentals of hospice compliance: what is it and what are the implications for the future? An overview for hospice clinicians, part 1

This article, Part 1 of a 2-part series, provides an overview of the current Medicare compliance climate and its implications for hospice providers. Content focuses on the 7 elements of a comprehensive compliance framework as defined by the Health and Human Services Office of the Inspector General in its 1999 Compliance Guidance for Hospices. A brief case example is provided and serves to set the stage for Part 2, which will explore hospice-specific risk areas and specific risk-reduction strategies.     

Comfort care packs: a little bit of hospice in hospital?

The Comfort Care Pack initiative is an innovation designed to enhance the inpatient experience of end-of-life patients and their carers. The carer is given a pleasantly decorated box containing a variety of items for use by the patient or the carer themselves: snacks, toiletries and items to promote comfort. This project set out to evaluate the impact of these packs by reviewing the returns of the feedback questionnaires included with the packs. From the first 220 packs, 58 questionnaires were returned, giving quantitative and qualitative data. The response to the packs was overwhelmingly positive and they were much valued by the carers. This was the case despite the fact that relatively few of the items were actually used by the recipients. It is suggested that the value of the packs to recipients lies in the gesture of being thought about during what is a difficult time for them. The implications of this are discussed.     

The fundamentals of hospice compliance what is it and what are the implications for the future? An overview for hospice clinicians part 2: Hospice risk areas

This article, Part 2 of a 2-part series, continues the examination of the Medicare compliance climate and its impact on hospice providers. This 2nd part focuses on hospice-specific compliance risk areas and specific risk-reduction strategies. The case example from Part 1 is continued.