Pathways - Caring for Life Blog

Yogurt & Colorectal Cancer

2012-02-07T08:00:00.000-08:00

Yogurt may confer some degree of protection against colorectal cancer (CRC) according to a prospective study done in Italy. Yogurt intake was found to be inversely associated with CRC risk.

More than 45,000 volunteers participated by completing dietary questionnaires that included specific questions about yogurt intake. In the following 12 years 289 participants were diagnosed with CRC. High yogurt intake was significantly associated with decreased CRC risk, suggesting that yogurt should be part of a diet to prevent the disease.

The protective effect of yogurt was evident in the entire cohort, but was stronger in the 14,178 men in the study.

The study, done at Fondazione IRCSS Istituto Nazionale Tumori, Milano, Italy, was published in the International Journal of Cancer. 2011; 129(11):2712-9 (ISSN: 1097-0215)

Discussing Goals of Care with Very Ill Patients

2012-01-31T08:00:00.000-08:00

“Words matter. What clinicians say and how they say it hugely affect patients. Communicating about emotionally and medically complex topics such as advance care planning, preferences for care, prognosis, and death and dying is challenging,” Steve Pantilat, MD, Professor of Clinical Medicine and Director of the Palliative Care Unit at UCSF wrote in a 2009 JAMA article.

Pantilat recently spoke to an audience of more than 100 physicians and other health care professionals at a Nov. 29 ethics conference held at El Camino Hospital in Mountain View on “Better Words to Say: Communicating with the Very Ill Patient.”

“It’s not about the patient’s willingness to have this kind of conversation, but about [physicians’] willingness to have the conversation,” said Pantilat.

Discussing end-of-life issues with patients is not associated with depression, sadness, terror or worry according to research done by Wright and published in JAMA. In fact, this sort of conversation leads to better quality of life, fewer invasive interventions and better outcomes for caregivers. But how do we go about having the conversation? Here are some of the highlights of that talk and some useful approaches Steve Pantilat has learned over the years.

Ask open-ended questions to establish what the patient and family know.

Examples of questions he asks are: “When you think about what lies ahead, what worries you the most?” and “When you think about the future, what do you hope for?”

The answers to these questions may be very different than you anticipated and may guide care decisions. For instance, if a patient says he wants to have chemotherapy and visit his home town, the physician may recognize that the visit may not be feasible after chemotherapy, and that if it will not significantly change the outcome of the disease, perhaps the patient should take the trip first.

Listen and sit down.

Pantilat referred to a well known study done in the 1970s that demonstrated that patients perceived their physicians’ visits to be much longer than they actually were when the physician sat down to talk with them.

Pantilat suggests that physicians listen for at least two minutes before talking (which he admits may seem interminable at the time). He emphasizes the value of not interrupting since most important things don’t come out at the very beginning of a conversation.

Avoid jargon, use simple language and check understanding.

Patients will often nod as though they understand although they are clueless to the meaning of what you are saying. Pantilat says that the answer is usually “No” to the question “Do you have any questions?” But he has noticed a distinct difference when he subtly rewords the question to say “What questions do you have?”

“Accuracy is not critical,” said Pantilat. Patients and families don’t need to know an exact prognosis, but they do need a realistic frame of reference. He suggests using ranges such as “hours to days,” “days to weeks,” or “weeks to months.” One person may interpret “not long” as days while another may think it refers to a year.

Offer a prognosis.

“False hope is not hope because it is not based in reality,” said Pantilat, reminding his audience of the research published in the NEJM that found that TV patients had a 79% rate of survival with quality life after CPR, whereas in real life the numbers are far grimmer. The problem is that the public gets its information from television.

Discuss death explicitly.

Talking about death can be a great relief, says Pantilat. He suggests practicing difficult conversations and in this setting suggests phrasing such as, “Many patients with lung cancer tell me they think about the possibility of dying. They have questions about this. How about you?”

Remain sensitive to the patient’s culture.

Pantilat cautioned about assuming all persons of a particular culture have similar beliefs and suggests the solution lies in asking, “In your family how do you make medical decisions?” His experience has told him that patients often know much more than physicians or families realize. Although they may never have been spoken to directly about their disease, the visits to a cancer center, increasing treatment, arrival of family members from afar and a host of other clues tell them about their condition.

Pantilat does caution that we should always ask how much the patient wants to know, regardless of what the family has said. To be sensitive he often asks, “I have information about your condition. Some patients want to know the details, others prefer to have me talk to someone else. How do you feel?”

Use better words.

There is never a time when it is appropriate to say, “There is nothing more we can do.” Pantilat suggests instead, “There is no more we can do to cure your disease.” And rather than arguing with family members about the futility of treatments, Pantilat likes to put himself on their side by saying, “I wish there was something we could do to make your cancer go away.”

Ask helpful questions.

Questions such as, “Would you like us to do everything possible?” are not helpful and will always be answered “Yes.” However, “everything” may mean all possible curative medical treatments to the physician, while the family interprets it to mean all possible efforts aimed at keeping their loved one comfortable. Pantilat finds it clarifying in this situation to ask, “How were you hoping we could help?”

Be aware of your non-verbal communication.

Asking someone if they have any other questions while your hand is on the door sends a loud message and the answer will usually be, “No.”

Pantilat concluded by acknowledging that this process is usually more than one conversation and that physicians should share the responsibility with others such as the palliative care team, social workers, and chaplains. Discussions about goals of care are good for patients and families: Use better words.

More Seniors Living Beyond 90

2012-01-24T08:00:00.000-08:00

1.9 million Americans have reached the age of at least 90 years according to a recent report by the National Institute on Aging and the US Census Bureau. This comprises nearly 4.7% of the entire population.

Over the last 30 years, the size of this age group has tripled, creating changes in the landscape of elder housing and elder care. Nearly 20% of those 90 and older live in nursing homes. Senior living facilities are home not only to older, but sicker, residents now.

“Traditionally, the cutoff age for what is considered the ‘oldest old’ has been age 85,” Census Bureau demographer Wan He said. “But increasingly people are living longer and the older population itself is getting older. Given its rapid growth, the 90-and-older population merits a closer look.”

The complete report can be found at: http://www.census.gov/prod/2011pubs/acs-17.pdf.

Dysphagia & Managing Oral Secretions

2012-01-10T10:18:00.000-08:00

As residents near the end of life, one of the signs most often encountered is the loss of the ability to swallow. This article will look at how to manage this problem.

How It Begins

It often begins before the resident is actively dying with dysphagia, or trouble swallowing, usually caused by weakness and poor neurologic function. The resident may cough, clear his throat, or sputter while eating or drinking. Thickening fluids may help to start with, since thicker liquids are less likely to pass into the trachea which can lead to aspiration pneumonia.

Preventing Pneumonia

Later, even making fluids thicker is not enough. The gag reflex and reflexive clearing of the throat decline. It is probably time to stop feeding the resident at this point to prevent pneumonia. Usually this comes at the same time as loss of appetite; the resident does not experience hunger any longer and though feedings stop, it does not cause distress. It is important to take the time to explain this process to the family.

Noisy Breathing

As the resident becomes less aware and it is clear that death is nearing, those at the bedside may hear a rattling, gurgling, crackling noise with each breath. This is caused by the build-up of secretions in the throat; the resident cannot swallow them the way most people normally do. This noise is sometimes called a “death rattle,” (although this term should never be used around families and caregivers).

Medications

These noisy respirations can be very disturbing to family and caregivers. It may be helpful to try to dry the secretions by using an anticholinergic medication such as atropine or scopolamine.

Atropine drops (normally used in the eye) may be ordered for administration under the tongue and scopolamine patches (often used to prevent motion sickness) can be applied behind the ear. Both seem to work equally as well, and neither affects survival time. These drugs can be used in the unconscious dying patient before noisy breathing begins to prevent it from happening.

Non-Drug Treatments

Repositioning the resident can help to clear the secretions. Turning the resident far to one side and then the other (to a semi-prone position) may allow the secretions to drain through the mouth (be sure to have a towel ready for drainage). Raising the foot of the bed very briefly while on the side may also help, but never leave the resident in this position for more than two or three minutes at the most.

Suctioning

Oropharyngeal suctioning is not recommended. Suctioning can be very distressing to the resident and family, and it is often ineffective since the secretions are usually beyond the reach of the suction catheter. Suctioning can also stimulate more secretions.

A Quick Review of COPD

2012-01-03T10:22:00.000-08:00

A Progressive Disease

Chronic Obstructive Pulmonary Disease is a lung disease that causes a blockage or narrowing of the airways. This results in decreased ability to move air in and out of the lungs. The disease has a slow, progressive course and is irreversible.

Statistics

COPD is the 4th leading cause of death in the US: 120,000 Americans annually. It is expected that by 2020, COPD will become the 3rd leading cause of death worldwide. Men are more likely to have COPD than women, and it usually occurs in those over 40 years old.

Types

There are three types of COPD and all of them require the patient to work very hard at breathing.

Emphysema: Air sacs (alveoli) of the lungs are damaged and enlarged. This reduces the amount of surface area for the exchange of oxygen and carbon dioxide. Less oxygen can move into the body and less carbon dioxide can be expelled.
Chronic Bronchitis: Inflammation of the bronchial tubes which can cause them to swell. This can leave less room for air movement.
Bronchiectasis: Permanent widening of the large air tubes which begin at the bottom of the trachea and branch into the lungs.

Causes

The most significant risk factor is, of course, smoking. The American Lung Association estimates that 80% to 90% of people diagnosed with COPD are chronic smokers. Secondhand smoke is also a major factor, causing 3,400 lung-related deaths annually. Research also shows a link between air pollution and work-related exposure, such as coal mine dust, silica, cotton and grain dust.

Symptoms

Most symptoms include: breathlessness with any activity, chronic cough, increased sputum production, wheezing, chest tightness and frequent chest infections.

Other signs and symptoms may include swelling, weight gain and obesity, (which may be a side effect of medication therapy), a round barrel chest, coughing blood, and cyanosis (bluish coloring often seen around the mouth).

Diagnostic Testing

To make a diagnosis of COPD, a complete assessment must be taken including family history, environmental and occupational exposure and smoking history. Additional tests may include:

Blood work such as arterial blood gases, hemoglobin and hematocrit levels
Chest x-ray
Pulmonary function tests
Bronchoscopy
Pulse oximetry

Treatment

The main treatments for COPD include medications (bronchodilators, expectorants, antibiotics and corticosteroids), oxygen therapy, pulmonary rehabilitation, and at the end of life, morphine to ease shortness of breath.

Combating Fatigue in Cancer

2011-12-26T10:36:00.000-08:00

Pilot Study

A team of researchers from Australia and New Zealand conducted a small pilot study to help determine an appropriate dose of methylphenidate hydrochloride, a central nervous system stimulant, to treat fatigue in patients with advanced cancer.

They reported in Journal of Palliative Medicine that 5 mg twice daily would be an appropriate dose to test in a definitive study. Ten patients provided consent.

After a three-day assessment, patients received titrated methylphenidate hydrochloride at doses ranging from 5 mg a day to 15mg twice a day. Nine patients completed eight days and five received the maximum dose at day 15. Three patients were satisfied with the results at a lower dose and were not willing to increase it.

The team noted a pattern of rapidly improving fatigue and depression at 5 mg twice daily.

Journal of Palliative Medicine, Volume 13, Number 10, Oct. 2010

Spiritual Pain in Advanced Cancer: Symptom for Hospice Chaplains to Address

2011-12-19T10:30:00.000-08:00

Quality of Life Can Improve

A vast majority of advanced cancer patients receiving palliative care consider themselves spiritual and religious. But spiritual pain is still common and is linked to lower quality of life. This is another place in which the holistic hospice approach to mind and body may improve life’s final stage.

A study done by the Division of Geriatrics and Palliative Medicine, The University of Texas Medical School at Houston, Texas, examined the frequency and intensity of spirituality, religiosity, and spiritual pain, and how spiritual pain was associated with symptom expression, coping, and spiritual quality of life.

Researchers interviewed 100 patients with advanced cancer and had them complete questionnaires assessing their symptoms and ability to cope.

Spiritual pain was reported in 44%, and was associated with lower spiritual quality of life. Patients with spiritual pain reported that it contributed adversely to their physical/emotional symptoms. There was a trend toward increased depression, anxiety, anorexia, and drowsiness among patients with spiritual pain, although this may not have been significant after corrections.

Every Pathways Hospice patient can have visits from extremely well qualified spiritual care counselors to give unbiased spiritual or religious support to patient or family members, to identify and resolve spiritual concerns, to explore the meaning of life, to administer sacraments, or to be a warm listening presence when needed.

This study can be found at J Pain Symptom Manage. 2011; 41(6):986-94 (ISSN: 1873-6513).

Fiber in Diet Reduces Risk of Breast Cancer

2011-12-12T10:40:00.000-08:00

What do avocados, blackberries, oatmeal and black beans have in common? They are all very high in fiber. So?

A study done at Soochow University in China has demonstrated that raising your fiber intake can significantly reduce your risk of breast cancer.

After examining 10 studies of dietary fiber intake and risk of breast cancer involving 16,848 cases and 712,195 participants, they found that the more fiber added to the diet, the lower the breast cancer risk fell.

12 Great Sources of Fiber

Avocados, artichokes, raspberries, blackberries, lentils, black beans, broccoli, vegetable beef soup, pears, apples, oatmeal, and barley.

The study was published in the American Journal of Nutrition, 2011; 94(3):900-5 (ISSN: 1938-3207).

Egg Allergy Doesn’t Rule Out Flu Shots

2011-11-21T10:43:00.001-08:00

New Recommendation

For many years when fall and flu shots rolled around, patients were told that if they have allergies to eggs they should not have a flu shot. The reason cited was that chicken eggs are used in vaccine production and there were concerns about traces of egg protein triggering reactions. Turns out, it’s probably okay.

New recommendations by the American Academy of Allergy, Asthma & Immunology (AAAAI) say that anyone with a history of suspected egg allergy should first be evaluated by an allergist or immunologist for testing and diagnosis but can probably receive the vaccination.

Matthew J. Greenhawt, M.D., M.B.A., clinical lecturer at the University of Michigan Health System and James T. Li, M.D., Ph.D.,chair of the Division of Allergic Diseases in the Department of Internal Medicine at Mayo Clinic, co-authored the AAAAI guidelines based on recent studies.

Because about 20% of the US population comes down with the flu each year, vaccination is important. Many studies have shown few reactions, with a scattering of hives or mild wheezing. No skin tests are needed, as results aren’t predictive.

There is also no need to divide the dose. Single-dose studies support giving the entire vaccine dose at one time. Egg-allergic patients must get the inactivated flu shot since this is what was used in research, and they cannot receive nasal vaccine.

You can read more about these guidelines and the research findings at: http://www.aaaai.org

Literacy Affects Health

2011-11-21T10:40:00.001-08:00

Higher Mortality

Low health literacy is significantly associated with higher mortality in patients with heart failure. This is the conclusion drawn by researchers who designed a retrospective study of patients at Kaiser Permanente in Colorado.

They examined cases of heart failure from 2001 to 2008, surveying patients by mail. The patients were also followed for a median of 1.2 years. Health literacy was assessed using well-established screening questions and categorized as either “adequate” or “low”. Then researchers looked at hospitalization and mortality for all causes.

The survey response rate was 72% (1547 of 2156); 17.5% of responders had low health literacy. Low health literacy was associated with:

Increased age
Lower socioeconomic status
Less likelihood of having at least a high school education
Higher rates of co-morbidities

In multivariable Cox regression, low health literacy was independently associated with higher mortality (unadjusted rate, 17.6% vs 6.3%; adjusted hazard ratio, 1.97 [95% confidence interval, 1.3-2.97]; P = .001), but not hospitalization (unadjusted rate, 30.5% vs 23.2%; adjusted hazard ratio, 1.05 [95% confidence interval, 0.8-1.37]; P = .73).

This study was published in the Journal of the American Medical Association (JAMA. 2011; 305(16):1695-701 (ISSN: 1538-3598).

People Want Palliative Care Info

2011-11-21T10:38:00.001-08:00

Education Gap

78% of Americans think palliative care and end-of-life treatment should be a part of public discussion, and a whopping 93% believe such decisions should be a top priority for the US healthcare system, according to a survey released this year conducted by the news magazine National Journal and the Regence Foundation.

More than 70% of the respondents agreed with the statement: “It is more important to enhance the quality of life for seriously ill patients, even if it means a shorter life.” While 23% said it was “more important to extend life through every medical intervention possible.”

Panelists at the health summit at which the data was presented agreed that patients want to make their own decisions. “It’s really about control,” said John Rother, executive vice president of policy, strategy, and international affairs at AARP. The survey’s findings suggest many Americans want to better understand what is available to those who have few options left.

Around 23% of those surveyed said they thought the law allows government to make end-of-life decisions for older adults. Only 40% correctly answered that the law does not include “death panels,” while 36% said they didn’t know.

These results illustrate the huge need for education. Of those surveyed, 54% said their doctor or healthcare provider was the source of information on end-of-life issues, and 75% said they got their information from family and friends. Only 33% said they trusted politicians and elected officials for accurate information.

Those polled gave the US healthcare system a “C” grade of 5.5 on a scale of 1 to 10. 36% scored the system 7 - 10; 41% rated it 4 - 6; 21% gave scores of 0 - 3.

Pathways has a robust palliative care program under the auspices of our Home Health department. It is designed for those with serious illness who may still be receiving curative treatment and who may have up to 12 months to live.

More information about this survey can be obtained at: http://www.nationaljournal.com/healthcare/no-death-panels-please-but-poll-shows-americans-can-handle-end-of-life-chat-20110308

Should I Tell My Patient Death Is Imminent?

2011-11-21T10:33:00.001-08:00

Does Not Increase Anxiety

When your patient with cancer is terminally ill and you have a good sense of the short prognosis, should you tell him? It is a well-established practice for American physicians to be forthcoming about prognosis, but not so well established when death is just around the corner.

A study recently published online suggests that keeping the patient fully informed in the final days means that they are more likely to have their preferences met and to die in their preferred place. Their family members are also more likely to be prepared for the death and to be offered bereavement support.

Researchers in Sweden looked at more than 1,000 cases in which patients were informed of their imminent death and compared this with a similar number who were not informed. Results showed no differences with regard to pain control, nausea, anxiety, confusion, respiratory tract secretions and other end-of-life symptoms.

“People vary about the extent they want to know the truth, if they want to know at all, and in their understanding of what constitutes telling the truth,” the authors wrote. But, they concluded, “being informed about imminent death does not lead to more unrelieved pain and anxiety during the last week of life.”

The study concludes that, “providing information of imminent death to a patient with cancer at the end of life does not seem to increase pain or anxiety, but it does seem to be associated with improved care and to increase the likelihood of fulfilling the principles of a good death.”

The study appears in the Journal of Clinical Oncology, July 2011.

Coffee May Help Depression

2011-11-21T10:03:00.001-08:00

You may have read about the benefits of one or two cups of coffee a day: reduced risk of type 2 diabetes, Parkinson’s disease and dementia. Now it looks as though a little java may also decrease the risk for depression.

“There is certainly much more good news than bad news, in terms of coffee and health,” says Frank Hu, MD, MPH, PhD, nutrition and epidemiology professor at the Harvard School of Public Health.

New research published after a 10-year study of more than 50,000 older women suggest that the risk for depression may decrease as coffee consumption increases. Those who drank 2-3 cups a day had a 15% decreased risk of depression compared to women who drank one cup a day or less.

“People have often worried that drinking caffeinated coffee might have a bad effect on their health, but there is more and more literature, including this study, showing that caffeine may not have the detrimental effect previously thought,” according to lead author Michel Lucas, PhD, RD, epidemiologist/nutritionist at Harvard School of Public Health in Boston.

The study is published in the September 26 issue of the Archives of Internal Medicine.

How Common Are Medical Errors?

2011-11-18T11:08:00.001-08:00

Researchers at the University of Utah led by Dr. David Classen found that about one of every three patients hospitalized in the US will experience some sort of mistake during their stay. The findings indicate the error rate may be as high as 10 times greater than estimated using older methods.

“It’s clear that we still have a great deal of work to do in order to achieve a health care system that is consistently high-quality -- that is, safe, effective, patient-centered, efficient, timely, and devoid of disparities based on race or ethnicity,” said Susan Dentzer, editor-in-chief of Health Affairs, a peer-reviewed journal that explores health policy issues of current concern that published the research.

The medical errors found ranged from decubitus ulcers and staph infections to objects left in the body after surgery. It is estimated that medical errors that cause harm to patients annually cost $17.1 billion in 2008 dollars.

“A key challenge has been agreeing on a yardstick for measuring the safety of care in hospitals,” the researchers wrote. To find the best yardstick, the team tested three methods of tracking errors on the same set of medical records from three different hospitals.

Among the 795 patient records reviewed, voluntary reporting detected four problems, the Agency for Healthcare Research’s (AHR) quality indicator found 35, and the Institute for Healthcare Improvement’s tool detected 354 events -- 10 times more than AHR’s method.

“Our findings indicate that two methods commonly used by most care delivery organizations and supported by policy makers to measure the safety of care ... fail to detect more than 90% of the adverse events that occur among hospitalized patients,” the team wrote.

The research was supported by the Robert Wood Johnson Foundation, which focuses on U.S. healthcare issues.

Grief and the Holidays

2011-11-17T11:25:00.001-08:00

Remembering

With the holidays come reminders of their loss for those who are grieving. Others are savoring a time of joy, sharing memories, and coming together in love. For those who are grieving, the holidays are a vivid reminder of who is NOT there.

Many grieving people find this the most difficult time of the year. They cannot forget and cannot bury the pain. Their hearts, minds and bodies are grieving and not functioning in their full capacities, as though part of them is missing. These are natural feelings—they are all a part of the process—they can share them, accept them, and feel them.

Ways of Coping

As the holidays approach, it may help for those who are grieving to start with a blank slate. Accept that they may not have the energy or desire to accomplish all the things that people have come to expect during the holidays.

Rather than do things automatically, they can discuss and think about what they really want to do, what they don’t want to do, and what will be difficult but they want to try anyway. Grief experts encourage people not to be afraid to change traditions or start new ones.

Equally important is to acknowledge how one feels. Many recently bereaved worry they will spoil the holidays for others. According to families Pathways has counseled, the most painful thing is when they try to keep their feelings inside.

If friends or family members take the initiative to talk about the person who has died, it relieves the tension and creates an opportunity for sharing.

Managing Grief

While there are no universal methods for healing and coping, there are some concrete things a person can do that may make the holidays easier and provide an opportunity to honor loved ones who have died.

Grieving families can:

Acknowledge the grief; accept whatever mood occurs.
Remember they are not alone. Attend a remembrance event or grief support group.
Give themselves permission to let go of certain traditions—it’s okay to make changes.
Share plans with others; let them know how they can help.
Reserve time to honor the loved one quietly, alone or with others—light a candle, place a photograph on the table, share memories, or make a memorial donation.

And finally, grieving family members should remember to care for themselves at this time.

Visiting a Friend or Loved One with Dementia

2011-09-09T14:10:00.000-07:00

Dementia is a progressive disease that is measured not in months, but in years. As the disease progresses it may become difficult to visit the patient—he may not recognize you, she may not be able to converse with you, or you don’t know if the person even realizes you are there.

Why Visit?

You may question if there is any reason to visit any more. With dementia it can be hard to know how to be supportive, especially at the end of life.

There is a good reason to visit—you can make a difference. The focus of visits shifts; instead of expecting an exchange of pleasantries, your motivation becomes, “What can I do to improve quality of life?”

Your visit really begins with you, at home. You may want to think about your feelings. Am I frightened I too will end up with dementia? Am I afraid of the end of life? What do I want to accomplish in my visit?

Planning the Visit

Visiting a person with dementia can be frustrating and unrewarding when you feel as though there is nothing you can do. You may be able to make the visit more meaningful with some preparation.

Gather together some supplies so that you are prepared for whatever the situation is when you arrive. A few ideas are:

Knitting, a crossword or a book to read if the patient is sleeping
A picture book with large colorful or interesting images
Interesting photos someone has sent you in an email
Music you know the patient likes
A newspaper column, such as Dear Abby or the sports page to read aloud
A photo album
A special memento
A letter from a mutual friend to share
A nail file and polish for a manicure
The patient’s favorite perfume
A favorite food
Lotion for a hand or foot massage
A pet, if allowed

The sky is the limit. Use your imagination and everything you know about the person to come up with ideas of things to share. The resident may want to listen to news about her book club, his former poker buddies or the doings at church.

The Visit

Begin with the basics. The visit will be more successful if the resident is clean and dry, not hungry, and comfortable. Ask for help if needed.

Pain can sometimes appear as negative behavior. People with dementia may withdraw, strike out or display other “bad” behaviors when in pain. If you have seen behavior changes that you suspect may be due to discomfort, you may want to ask the caregiver for a trial of pain medicine.

Think about providing comfort through the senses.

Touch

We all need to be touched, but seniors are often deprived of this essential element to wellbeing.

Our society is youth-centered and may look at wrinkled skin as ugly, not weathered with experience.
Among hospitalized patients, the only ones touched less than the elderly were people who were psychotic.

Touch can be “instrumental;” that means required to carry out activities such as bathing or dressing. But research shows that people with dementia can tell the difference between this and “expressive” touch. Expressive touch is when we hold hands, put an arm around the person, or give a back rub or hug. This conveys acceptance, nurturing and caring.

Expressive touch helps the elderly feel less isolated, dependent and depressed.

One researcher found that it also made the toucher feel better. They felt this non-verbal communication conveyed trust, reassurance, and love, and that it instilled hope.
Others described touch as making a person feel psychologically worthy and have a sense of being cared for and cared about.
It is no coincidence that the ultimate form of punishment is solitary confinement—no touching.

Caring touch can trigger the brain to release endorphins and serotonin—natural chemicals that suppress pain and depression. This is one reason massage can lower the perception of pain.

Massaging a loved one’s hands or back can help significantly while waiting for pain medicine to work.
Brushing the resident’s hair and applying lotion have the same affect.

Hearing

We know that hearing seems to remain intact until the very end of life. This gives us an opportunity for providing comfort.

Soft music can be very soothing to an agitated resident.
If the resident has been religious, he may appreciate hearing hymns and spiritual music. Bring in CDs or tapes of his favorites and a CD player to play them on.
You can even sing or hum a familiar tune.
Bring in a music box.

Communication

If you are not close, calling residents with Alzheimer’s disease “sweetie,” “dear,” “cookie,” or “honey” may cause more resistance to care. Experts have known for a long time that mentally competent elderly residents in nursing homes are irritated by being “talked down to.” Recent research shows people with dementia are more agitated when talked to this way.

What they found was that residents were more resistant if the communication was what they dubbed “elderspeak.”

Saying things like, “Are we ready for dinner?” implies that the person isn’t able to act independently. An alternative would be, “Are you ready for me to help you with your dinner?”
The tendency of caregivers to use “elderspeak” increases with the caregivers perceived level of infirmity of the resident.
We need to remember that residents were high functioning adults. The more we remember their earlier lives, the more we respect them as people than as a disease.

Just chatting can be very reassuring. “I spoke with Michael today, back in Virginia. He says he and Alice are going to take a trip to Vermont. They are going as soon as the snow melts. It’s February now, so it may be a couple of months.”

Maintain the resident’s dignity in small ways: use terms like “disposable briefs” instead of “diapers.” Remember to speak slowly. People with dementia take longer to process what you have said.

Sense of Smell

This sense is so basic that when we smell a certain odor, it can bring back memories from decades ago.

Aromatherapy takes advantage of this by providing pleasant smells that might bring back pleasant memories.
Bring a rose, a lavender sachet, or a scented candle that smells like pumpkin or apple pie.
A favorite perfume or aftershave can brighten spirits.

Taste

Bring in a favorite food or drink. The resident may love Fritos or M&Ms and they won’t be on the menu in assisted living.
Cleaning the mouth with minty toothpaste or mouthwash on a 4x4 may be refreshing.

We have to be very careful about anything in the mouth at the end of life. With dementia, all the muscles get weaker and weaker—including the muscles for swallowing.

Food or fluids can easily get into the airway, causing aspiration pneumonia.

Textures

A resident in a facility has little chance to experience unusual textures, such as soft fur or a smooth, cool stone. A pet or even a stuffed animal may provide comfort.
Wrapping someone’s hands or feet in a hot, wet towel might feel very soothing and relaxing—the spa treatment!
Find a way to warm a flannel blanket to wrap the resident in.
Smooth the sheets or put cool, clean sheets on. Change the pillow case or turn over the pillow.
Open a window to feel a breeze.

Imagination

Use your imagination. Think about what would bring you comfort. What would feel good to you? For each visit plan a simple, new, creative way to bring pleasure, serenity or comfort. Quality of life will improve for both of you.

Want to Learn More?

Visit our website's Caregiver Resource page for more information and helpful hints when caring for a friend or loved one with dementia.

Grateful to Give Back: An Interview with Pathways Volunteer, Bill Jennings

2011-08-29T14:01:00.000-07:00

Pathways Home Health & Hospice recognized Bill Jennings of Milpitas, California for outstanding volunteer service by honoring him with the Kennedy Award. Bill has been a volunteer at Pathways Home Health & Hospice since 2006, and is an active member of both bereavement and patient care teams.

A retired trainer with Sony Electronics, Bill has found many opportunities to adapt his professional skills to his volunteer work at Pathways. He uses his interpersonal skills when visiting patients and their families, where he provides companionship, and comfort. He uses his technical skills by creating and maintaining two databases for tracking the non-profits’ bereavement library and Integrative Therapies practices.

We recently sat down with Bill to ask him a few questions about his volunteer experiences at Pathways.

What does being a Pathways volunteer mean to me?

Self fulfillment, personal growth
Appreciation from the patients and family you serve

What type of volunteer work do you do and which do you like the best?

Hospice visits for companionship with patients and caregiver relief
Bereavement calling to families who have lost a loved one
Integrative therapies committee

What would you say to those who are considering volunteering at Pathways?

So many opportunities to give back
What skills do you have that you would like to share with others?

We appreciate you taking the time to talk with us today. Thank you, Bill!

Benefits of Volunteering

Volunteers often find that their greatest satisfaction comes from contributing to the wellbeing of others. They also have the opportunity to apply their talents in fields different from their usual work. For some, volunteering may even lead to a new career. Their gifts of time, energy, and skills fill a unique role that only they can provide. Many volunteers tell us that they learn from working with other dedicated professionals and volunteers.

Finding Your Niche at Pathways

To explore volunteer opportunities at Pathways, call the Manager of Volunteer Services in your area, or visit the “Apply to be a Volunteer” section of our website. After completing an application, you’ll meet with a representative from Volunteer Services to help you find your place at Pathways.

Contact Pathways

In Santa Clara County: 408.773.4219; in Alameda; Contra Costa Counties: 510.613.2017; and in San Francisco and San Mateo Counties: 650.808.4604. Or visit us online at www.pathwayshealth.org.

Sitting is a Risk Factor for Death

2011-08-23T12:20:00.000-07:00

Spending Leisure Time

If you get home from work and want to plop down in a chair for the evening—think again. You may want to take a break, but get moving again. A study of more than 120,000 people found that those who spend at least 6 hours of their leisure time sitting died sooner than those who sat less than 3 hours.

People who sit a lot and exercise little are at even higher risk of death, and the effect is stronger for women than men. The death rate was about 40% higher in women, and 20% higher in men. The least active women were 94% more likely to die and the least active men were 48% more likely to die. (100% would mean you were twice as likely to die.)

The study was conducted by the American Cancer Society over 14 years and looked at people 50-74 years old when the study began in 1992. The main risk linked to sitting was heart disease.

“It is beneficial to encourage sedentary individuals to stand up and walk around as well as to reach optimal levels of physical activity,” according to the study’s authors. The findings appear in the July 2010 issue of the American Journal of Epidemiology.

Melanoma: Look for the Ugly Duckling

2011-08-18T13:50:00.000-07:00

Atypical Even for Atypical

A group at Memorial Sloan-Kettering Cancer Center in New York found that moles in the same person tend to look alike, but a malignant melanoma will often look different from the individual’s mole pattern—the “ugly duckling sign.”

Identifying pigmented moles that look different from a person’s other moles—“even in those with multiple atypical nevi,” said Dr. Ashfaq A. Marghoob, is a practical way to spot malignant melanoma. His research was published in the Archives of Dermatology.

Marghoob and his colleagues had 34 people with varying levels of expertise identify ugly duckling moles in patients with several atypical moles. Participants included 8 mole experts, 13 dermatologists, 5 dermatology nurses, and 8 non-MD medical staff members. They were shown photographs of the backs and close-ups of moles from 12 patients who had five melanomas, at least eight atypical moles and 140 benign pigmented moles.

All five melanomas and benign moles were identified as different by at least two thirds of the participants. Investigators concluded that the usefulness of the ugly duckling method in malignant melanoma skin cancer screening by general health care providers and lay persons “should be further assessed.”

Managing Pain Without Medication

2011-08-09T12:51:00.000-07:00

In addition to medication for pain, there are other things we can do to reduce pain. Usually these are used in addition to medicine or while waiting for the medicine to work. But if a resident refuses pain medication, using these techniques may help.

Alternatives to Try

Distraction: This is an effective technique. It’s as though the brain can only pay attention to one thing at a time. Talking, watching TV, playing games or looking at photo albums are some examples. If the pain is severe, these will not work.

Deep breathing / relaxation exercises: Guide the person in deep, slow, rhythmic breathing. There are many relaxation recordings available that are easy to follow. You can suggest to family members that they purchase relaxation recordings and furnish a listening device.

Cold: A cold pack (gel pack, ice pack, or zip bag with crushed ice) helps inflammation or muscle ache. Wrap the pack in a towel; do not put the ice pack directly on the skin. Even if this does not relieve all pain, it may help to numb the area somewhat.

Warmth: A warm tub bath or warm packs can relax muscles that have tightened due to pain. A warm, wet washcloth applied directly to the affected area may help. Covering the cloth with plastic will help retain the heat longer.

Massage: This is an excellent way to distract from pain and relax tense muscles that make the pain worse. Lotion may reduce friction. You do not have to massage the painful area. Massaging another area of the body may distract the mind from pain.

Prayer / meditation: Some people find this very comforting and perceive less pain during prayer. There may also be rites or rituals that could comfort the resident. Ask family members about this.

Music: Music is another form of distraction that research has shown relieves pain. It does not matter what kind of music, whatever the resident likes will work. Again, family members can help provide information about musical tastes and recordings and a CD player.

Energy work / therapeutic touch: These are hands-on techniques in which the practitioner places his or her hands on the resident’s clothed body to achieve a transfer of energy.

Acupressure / acupuncture: These techniques apply pressure or needles to specific points on the body to relieve discomfort in other areas that are associated with those points.

Reflection / life review: Those nearing the end of life often want to reflect on the events of their lives and the people they knew. Asking about family members or the resident’s youth or birth place may assist in starting this kind of life review.

Pets: Research shows that pets improve mood, lower blood pressure and heart rate, and may serve as a good distraction from pain.

Innovative Program at Pathways

Pathways Hospice patients can take advantage of our well developed Integrative Therapies program. It provides innovative therapies such as guided imagery, comfort touch, music therapy, aromatherapy, massage, and pet therapy. These therapies are shown to reduce agitation in residents.

If you are interested in learning more about the Integrative Therapies program at Pathways, talk to Pathways staff, or visit our website: www.pathwayshealth.org. The Resources section includes downloadable information and simple tips for incorporating Integrative Therapies in your daily life too!

Men, Women, and Pain

2011-08-04T11:38:00.000-07:00

Rigorous research has concluded that men have a higher threshold for pain. In a large-scale prospective study of 700 patients conducted by physicians from Tufts-New England Medical Center and San Ignacio Hospital, Bogata, Colombia, researchers examined post-surgical morphine use. After adjusting for type of surgery and age, women had higher levels of pain intensity throughout the study than men, requiring an average of 30% more morphine on a per-weight basis than men to attain a similar decrease in pain intensity.

Research results have been mixed, some finding that men required more morphine after surgery than women. A very large Chinese study found women used significantly less morphine when using patient-controlled analgesia post-operatively, indicating that cultural, ethnic or genetic factors may account for differing research results. But in animal models, male rats exhibited greater analgesia than female rats to equal doses of opioids.

The researchers wrote that, “Sex differences in pain perception have been attributed to a different socialization process for men and women that influences bodily experience and the willingness to communicate distress. Hormone variations could also in part explain sex differences in pain experience and response to morphine.”

Hindus & Hospice

2011-07-28T15:52:00.000-07:00

Many Hindu beliefs align with hospice and palliative care goals. A senior research specialist at the City of Hope in Duarte explored the Hindu concepts of suffering, karma and reincarnation in a recent article in the Journal of Hospice and Palliative Nursing.

Susan Thrane, MSN, RN, OCN, explained that among other similarities, Hindus often believe that death should neither be sought or prolonged, values that reflect the hospice philosophy. However, they do sometimes believe that physical suffering is beneficial in that it can lead to spiritual growth, perhaps resulting in a better birth in a future life.

Although palliative and hospice care usually seeks to relieve pain and suffering, it also seeks to help individuals meet their personal goals, and sensitive to cultural beliefs.

Thrane found that Hindus tend to be family oriented, and may often defer health care decisions to the oldest son.

There are an estimated 2.3 million Hindus in the US.

Early Discussions About Prognosis Urged

2011-07-27T12:23:00.000-07:00

Individualizing Care

The American Society of Clinical Oncology (ASCO) is calling on physicians, medical schools, insurers, and others to help improve quality of life for people with advanced cancer by discussing the full range of palliative care and treatment options soon after patients are diagnosed with advanced, incurable cancer.

Currently, physicians talk about prognosis early in the course of advanced disease less than 40% of the time. (In addition to guidelines for physicians, ASCO also released a guide to help patients broach the subject of prognosis and care options with physicians.)

Critical issues are tackled in a comprehensive article published in the Journal of Clinical Oncology.

They include:

Consideration of clinical trials
Initiating conversations about poor prognosis
Guidelines for discontinuing cancer-directed treatments
Individualizing approaches to care
Empowering patients
Maximizing quality of life

“Patients with advanced incurable cancer face complex physical, psychological, social, and spiritual consequences of disease and its treatment. Care for these patients should include an individualized assessment of the patient’s needs, goals, and preferences throughout the course of illness,” say the authors.

The complete article can be accessed at: http://jco.ascopubs.org/content/early/2011/01/24/JCO.2010.33.1744.full.pdf+html

Time for Hospice?

Pathways can assist you in managing the care of complex patients, while providing care at home.

We can help you determine the likely prognosis and if the life expectancy is six months or less, we can suggest ways to approach the patient and family about changing the focus of care from cure to comfort.

If you like, Pathways can have a nurse visit to explain hospice to appropriate patients and families, so that they will have sufficient information to make an informed decision about using their hospice benefit.

Power of Positive Thinking

2011-07-26T12:22:00.000-07:00

A series of lab experiments conducted in Europe found that those patients who expect their analgesics to work get relief from their pain. Those who were told their painkillers had been discontinued had more pain, even though they were actually continuing to receive the same dose. A patient’s expectations about the effectiveness of a pain drug appear to override the properties of the drug itself.

Scans Illustrate Phenomenon

Patient MRI scans conducted during the research show that, “volunteers had more activity in areas of the brain involved in memory and anxiety when they were expecting pain versus when they were expecting relief. When the volunteers were told the drug would work, there was a boost in brain activity in areas associated with ﬁghting pain,” says study author Dr. Ulrike Bingel, from the department of neurology at the University of Hamburg Medical Center in Germany.

Although the placebo effect is well documented, there is less research on the “nocebo” effect, in which patients have negative experiences when warned about the side effects or lack of effectiveness of a treatment, even if they are taking a placebo.

“This tells me that when we’re talking to patients and presenting therapy, the more positive we are about how the therapy is going to impact them, the better outcomes we’re going to have,” says Carla Rubingh, a pain management specialist and assistant professor of pharmacy practice at the University of Nebraska Medical Center in Omaha who was not involved in the study.

Benefits of the Mind-Body Connection

Pathways is home to an innovative Integrative Therapies Program that includes guided imagery and meditation to help patients find comfort and relief. Relaxation techniques use the mind-body connection to achieve relaxation. Using simple suggestions, the practitioner guides the patient or family member to make the changes they wish to achieve in their physical or emotional state. This is very effective in reducing stress and anxiety, and is helpful in pain management.

For more information about Integrative Therapies at Pathways visit our website and Integrative Therapies resource page for caregivers.

Cultural Sensitivity in Caregiving

2011-07-25T14:49:00.000-07:00

One definition of culture: "The constellation of values, norms and behavior guidelines that are shared by a group of individuals." -Reflections on Nursing Leadership, 1st Qtr 2001

American medicine applies certain bio-ethical principles, such as autonomy and truth-telling, that can be at odds with the values of some of the many cultures found in the Bay Area.

These Western bio-ethical principles are based on Anglo-European values, which are also reflected in American law. People from other cultures, whether caregivers, patients or families, may bristle when healthcare providers attempt to adhere to these values.

Withholding from patients information needed to make informed treatment decisions is illegal. Yet in many cultures telling patients negative information about their health condition is harmful to the patient. Talking to the patient instead of the oldest child may also be seen as an infringement on the proper role of the family.

Distrust of the system

Significant distrust of the healthcare system exists. In a group of culturally mixed elders in New York City researchers found:

Many equated less aggressive treatment with abandonment.
Many thought having an advance directive was harmful, especially if it burdened one person.
Most were reluctant to name anyone but a family member as a proxy or agent.

Another example would be the African-American history of slavery and exploitation as test subjects. African-Americans are half as likely as Anglos to opt for treatment to improve quality of life at the expense of length of life, even if pain will be constant.

People that are poorer or socially disadvantaged expect to be denied care and often regard advance directives as legal devices of the health care system to deny care. Some close-knit families feel that advance directives are destructive, and are incredulous on learning about laws that conflict with family decision-making.

One pattern seems to transcend almost all cultures: the elderly tend to have and prefer a passive voice in decision-making (e.g. “Doctors do the best they can”).

Cultural multiplicity

In one culture illness may be seen as a test of faith and withdrawing treatment may be construed as interfering with God’s will, while in another using extraordinary treatments may be considered interfering with God’s will.

Pacific Island cultures may feel dying outside the home will leave the departed wandering without a place to rest while in another Asian culture, Chinese, death may be seen as a harbinger of more bad luck for the family of the deceased, so the patient may want to avoid dying at home.

In many cultures, language and thought shape reality. Talking about death must be avoided in places as diverse as Greece, China, Italy, Mexico, Korea, and countries in the Horn of Africa.

Can’t Know All Cultures

Clearly, we cannot know all cultures. So how do we go about being culturally sensitive? Proceed with caution. Here are some things to bear in mind when working with a culturally diverse population:

Not all members of a particular culture share the same beliefs.
Find out how much the resident wants to know.
Ask who the patient would like to be informed about health issues.
Ask who to discuss treatments and outcomes with.

Above all, leave your cultural beliefs at the door when you go to work. Deciding what the patient should or should not know is a form of paternalism. It is also a distortion of the healthcare provider’s role as a patient advocate.

Consider taking a “values history.” Find out:

The patient’s perception of roles of caregivers and physician.
The importance of self-sufficiency to patient.
His or her attitude toward life (what brings enjoyment).
What the patient fears most.
What would be important to the person when dying?
What is their religious background and belief system?

Although we want to avoid stereotyping, generalities can be useful: “I know that in some families of your culture we see [ ]. Is this true in your family also?”

In a nutshell

Cultural sensitivity can be reduced to a few simple concepts:

Leave your own cultural beliefs and biases at the door.
Ask questions, then listen.

Bio-Ethical Principles

Autonomy: individual rights trump all
Truth-telling: patients have a right to full disclosure
Justice: resources should be equitably allocated.
Confidentiality: Patients have a right to privacy
Beneficence: act in the best interest of the patient
Non-malfeasance: do no harm
Responsibility: agree and adhere to regimen

At Pathways...

Early during the admission visit, the nurse asks the patient how much information about their health condition they would like to know, and whether they want to make their own healthcare decisions.

If they do not want to be the decision maker or know about their condition, we ask who they would like us to speak to.

If the patient does not speak and understand English very clearly, the nurse calls the AT&T language line and asks these questions via a translator. At subsequent visits a family member may translate.

Documenting this exchange meets the ethical principles of autonomy and truth-telling while respecting the patient’s cultural beliefs.

Dental Hygiene Related to Heart Disease

2010-10-20T09:39:00.000-07:00

New Evidence

You may not be a dentist, but get those patients to brush their teeth! People who brush their teeth less than twice a day run a higher risk of heart disease. These are the findings of a recent study published in the British Medical Journal.*

This is the first study of its kind and confirms the established fact that inflammation in the body (including mouth and gums) plays a significant role in the formation of atherosclerosis. Researchers analyzed health data from 11,000+ adults. After adjustment for established risk factors, the study found those with poor oral hygiene also had increased levels of C-reactive protein and fibrinogen.

Personal Care Services at Pathways

Pathways Private Duty provides care to assist older adults and the chronically ill in their activities of daily living, as well as with meal preparation, exercises and medication reminders. Our caregivers can also help with personal care such as bathing, grooming, and oral hygiene.

When it's time for care in your home, Pathways is here to help. Give us a call today at 1.888.600.2273 to arrange for an evaluation and assessment of your needs.

*Published online May 27, 2010 in BMJ; corresponding author is Prof Richard Watt (University College London, UK.)

Vitamin D May Reduce Falls in the Elderly in SNFs

2010-09-27T15:34:00.000-07:00

Dietary Supplements

Recent studies indicate that adding Vitamin D supplements to the diets of nursing home residents may reduce the frequency of falls, a leading cause of death and disability in the elderly.

Vitamin D deficiency is associated with muscle weakness, which can contribute to falls and fractures. Nursing home residents are especially vulnerable to falling due to advanced age, health problems, and weakened eyesight. In fact, approximately 50% of nursing home residents fall every year, and those who are injured become even more prone to future falls.

Although exercise, appropriate equipment, adequate staffing and a risk-free environment are important, research done at the Sydney Medical School at the University of Sydney in Ryde, Australia found that Vitamin D was a effective measure, although they are not sure why.

Fall Prevention Resources, Available Online

In an effort to increase awareness about fall prevention hazards the Fall Improvement Taskforce (FIT) at Pathways created colorful flyers that can be printed and used as check-off lists to ensure your environment remains safe and to minimize the risk of falls.

Topics include: “Did you know that clothing can contribute to falls?”; “Medications can increase the risk of falls”’; and “People with vision deficits are twice as likely to fall”.

These helpful resources can be downloaded via our website at www.pathwayshealth.org/resources.

Care at Home vs. Hospitalization

2010-09-20T12:25:00.000-07:00

Home Fares Better for Heart Failure Patients

Hospitalization, the standard venue for short-term medical care, may be hazardous for the elderly according to a study reported in the Archives of Internal Medicine in September, 2009.* The study evaluated the feasibility and effectiveness of physician-managed home care for selected patients with acute decompensation of chronic heart failure. The prospective, single-blind, randomized trial followed patients 75 years or older who had been hospitalized. They were randomly assigned to a Geriatric Home Hospitalization Service or a general medical ward.

Overall Improved Status

Findings demonstrated no significant difference in the number of deaths or subsequent hospitalizations, but the mean time until the first additional admission was longer for the patients cared for in their own homes. Only the home patients experienced improvements in depression, nutritional status and quality-of-life scores.

The research concluded that home care is a viable alternative to traditional hospital inpatient care for elderly patients with acutely decompensated CHF.

*Arch Intern Med. 2009 Sep 28;169(17):1569-75.

For more information about Pathways Home Health services for patients with chronic heart failure, please visit www.pathwayshealth.org/home-health.

When It Comes to Hospice, What's In It for Families?

2010-09-15T17:17:00.000-07:00

We Know What Patients Get

The multiple advantages of hospice for the family are often lost in our natural concern for the patient. We know the patient gets to stay at home with expert pain and symptom control as well as spiritual and emotional support. We know they have volunteers for companionship and the safety and energy conservation provided when a home health aide assists with personal care. And of course, there are the extras like massage with aromatherapy and music therapy.

“Unit of Care”

But how does the family benefit? In the very unusual insurance benefit that is hospice, Medicare defines the “unit of care” as the patient and family—and family is loosely defined to include close personal friends and significant others.

Relief from Caregiving

One of the pluses caregivers love most is relief from being the caregiver. It may be a couple of hours at the bank and beauty shop while a volunteer sits with the patient; it may be a 5-day paid respite stay in a skilled nursing while the caregiver recharges her metaphorical batteries; it may be a home health aide to do the physical care of bathing, dressing, shaving and linen changes several times a week; or it could even be a volunteer to grocery shop, run errands or walk the dog.

Emotional and Spiritual Support

A family at odds about healthcare goals may have a conference facilitated by a hospice social worker. There is some financial relief as hospice assumes the cost of medications, equipment and supplies related to the terminal illness—even over-the-counter products and disposable briefs. Then there is the assistance with funeral plans or insurance issues from skilled medical social workers—and sometimes a spiritual care counselor to preside over a memorial service or to pray with family members.

Easing the “Burden”

Those approaching the end of life often express regret over their perception of being a burden. It is a relief to them to find out that family members can call hospice 24 hours a day to talk to a nurse or arrange a visit if needed, and that their families can have the same spiritual and emotional support that they get. Patients are also comforted to know their family will have 13 months of support in their bereavement.

Time

And perhaps most important of all, because people who opt for hospice often live longer, patients and families have a few more cherished days or weeks to share this precious finale to life.

And Benefits for the Physician?

Physicians get fewer calls at night and on weekends
They have extra eyes and ears in the home.
Doctors get to be the heroes by giving patients and families better quality, and often quantity, of life.
Physicians have hospice medical directors with whom they can consult on complicated symptoms.

Research Confirms Many Live Longer with Hospice and Palliative Care

2010-08-19T13:47:00.000-07:00

Higher Quality of Life Reported By Palliative Care Patients, Study Reports

A recent study published in the New England Journal of Medicine found that among patients with non-small-cell lung cancer, those who received palliative care lived, on average, almost two months longer than those who received standard care. Researchers also found that the patients receiving palliative care reported a higher quality of life through the final course of their illness.

They also found that when patients received palliative care services, they were more likely to elect hospice services. "With earlier referral to a hospice program, patients may receive care that results in better management of symptoms, leading to stabilization of their condition and prolonged survival," wrote the authors of the study released August 18, 2010.

Pathways Provides Palliative Care

Pathways has a unique and vibrant Palliative Care program that is provided through Home Health. The criteria are that the patient has a prognosis of 12 months or less, has a skilled need (such as symptom management), and that he or she finds leaving home a considerable and taxing effort. (Patients may occasionally visit the barber, attend a special event, go for a drive or attend religious services and still be considered homebound, thus meeting the CMS criteria.) Patients may be receiving active, curative treatment simultaneously with Palliative Care.

“There’s an inaccurate perception among the American public that hospice means you’ve given up,” said J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization. “Those of us who have worked in the field have seen firsthand how hospice and palliative care can improve the quality of and indeed prolong the lives of people receiving care.” Schumacher added that “The time to learn about these services is before a person is in a medical crisis. Patients and families must learn about these options of care as soon as possible.”

A Growing Body of Evidence

A 2004 study found patients with 16 of the most common terminal diagnoses lived around 20 days (Journal of Pain and Symptom Management, September 2004). In 2007 a study of 4,493 patients found patients lived an average 29 days longer with hospice (JPSM, March 2007). This latest study adds to the body of evidence showing that many patients live longer with hospice and palliative care, and as a rule both patients and surviving families report better quality of life.

Hmmm... Chocolate!

2010-07-21T11:30:00.000-07:00

Chocolates

Food of the Gods

Hmmm. Truffles or chips, mousse or bars. No matter how you like it, there is nothing else like chocolate. But that delicious slice of cocoa-laced cake is often served with a helping of guilt. Maybe you shouldn’t feel so bad after all—it turns out chocolate has a good side.

Benefits

We all know it can soothe the soul, but did you know chocolate can also lower blood pressure and reduce the risk of heart disease and blood clots, according to a study published by the American Heart Association. Flavonoid compounds in dark chocolate are also the same healthful antioxidants found in fruits, vegetables, tea, and red wine. Chocolate even appears to reduce bad cholesterol (low density lipoprotein) while increasing good HDL (high density lipoprotein) cholesterol.

Chocolate also contains tryptophan, an amino acid that increases levels of serotonin, a natural antidepressant and stress reducer. And eating chocolate increases the body’s endorphin levels, thereby elevating mood and reducing pain. Dark chocolate also seems to improve the body’s use of insulin and glucose sensitivity, and it is rich in potassium and magnesium, and contains vitamins A, B1, B2, D, and E.

The Downside

Of course some of the benefits of eating chocolate are offset by its high fat, sugar, and calorie content. For example, a cup of broccoli and a cup of sliced apples have 20 and 57 calories respectively, while a cup of chocolate has 1,000 calories or more.

Not All Chocolate is Equal

The amount of beneficial flavonoids in chocolate depends on the type of cocoa bean and the methods used in processing. For instance, Dutch process” greatly reduces flavonoid content. White chocolate has no flavonoids since it has no “cocoa mass” and is not technically chocolate at all.

Dark chocolate, on the other hand, has fewer calories and two to four times the amount of flavonoids found in milk chocolate. Milk binds to the beneficial antioxidants, making them unavailable. To get the full benefits of antioxidants, you should avoid drinking milk with your dark chocolate. The ideal dark chocolate will have a “cocoa mass” content of at least 70%. With chocolate—the darker, the better.

Thank the Mayans

2,000 years ago the Mayans of Mexico and Central America began cultivating the pods of the cocoa tree that grew wild in the jungle. When mixed with water, chili peppers, and cornmeal, the ground cocoa beans made a spicy, frothy drink. Later the Aztecs adopted the bitter cocoa drink, usually enjoyed only by royalty and the privileged class. Spanish conquistadors brought cocoa beans to Europe in the 1500s where experiments with adding sugar to the new product flourished. The rest is history.

Indulge

So next time you want to indulge your sweet tooth with the silky, smooth, velvety texture of your favorite chocolate, enjoy it without guilt—you could be lowering your blood pressure!

For more information about Pathways Home Health, Hospice & Private Duty please visit our website at www.pathwayshealth.org.

Swearing Makes Pain More Tolerable

2010-07-09T17:07:00.000-07:00

Uttering a curse word when you stub your toe or hit your thumb with a hammer could actually make it easier to bear the pain. Swearing is a common response to pain, but until now there has been no research looking into this.

"Swearing has been around for centuries and is an almost universal human linguistic phenomenon," said Richard Stephens of Keele University in England, and one of the authors of the study.

Stephen’s team thought swearing would exaggerate the pain and people would tolerate it less. The opposite turned out to be true.

The researchers had 64 university students put their hands in a tub of ice water for as long as possible while repeating a swear word of their choice. The experiment was then repeated with the volunteers repeating a more common word that they would use to describe a table.

Contrary to what the researchers expected, the volunteers kept their hands submerged longer while repeating the swear word.

A Primal Response

Stephens says that swearing comes from deep-seated, primal, emotional brain centers. Just as a cat would screech if his tail as stepped on, a primate would make a noise, and in humans our language ability often transforms the screech into a swear word.

The researchers think that the increase in pain tolerance occurs because swearing triggers the body's natural "fight-or-flight" response. Stephens and his colleagues suggest that swearing may increase aggression (seen in accelerated heart rates), which downplays weakness to appear stronger.

"Our research shows one potential reason why swearing developed and why it persists," Stephens said.
The results of the study are detailed in the Aug. 5, 2009 issue of the journal NeuroReport. This article is adapted from the Live Science website.

For more information about Pathways Home Health, Hospice & Private Duty please visit our website at www.pathwayshealth.org.

When Capacity Is In Question

2010-07-07T17:02:00.000-07:00

Let’s say your patient is in the earlier stages of dementia when a malignancy is discovered. Who decides his treatment options? Despite his dementia, it’s possible that it should be the patient himself.

Decision-making capacity is defined as “the patient’s ability to make his or her own decisions about accepting or rejecting medical procedures or treatments,” according to an article in the Journal of Palliative Medicine (November 2009). Author Frank Clore, a hospice spiritual care counselor, lists five considerations for the healthcare professional:

Does the person understand the facts involved in making the decision?
Does he “have an appreciation of the nature and importance of the decision to be made, including potential alternative choices?”
Does he understand the benefits and risks of the decision?
Can he communicate the decision to others, including the reasons for making the decision?
Can he “deliberate based on consistent personal values?”

Clore suggests that you may be able to elicit the answers using these assessments:

Ask the patient to explain what he/she understands about his/her illness and about the proposed treatment.
Ask what the patient thinks about the proposed treatment, how it may help him/her, and what will happen if the treatment is not chosen.
Ask the patient to repeat his/her choice; answers should be consistent over time.

As with all patients, but especially those whose capacity for decision-making is in question, Clore reminds us the patient should be properly informed and free of coercion, and that the patient be “assessed in relationship to a specific decision, at a specific time, and in a specific context.”

For more information about healthcare decision making visit www.finalchoices.org or visit our website www.pathwayshealth.org.

Spiritual Support in Hospice

2010-07-04T04:00:00.000-07:00

Meaning of Life

When a patient may be facing the end of life, spiritual issues often begin to surface—people begin to ponder the meaning of their lives. Hospice is intended to care for not only the physical wellbeing of the patient, but the emotional and spiritual aspects as well. Toward that holistic end, Medicare mandates that hospices provide spiritual support (as they do in the military, another place where death is a possibility).

Spirituality is about those aspects of life that are not material; it is about relationships and finding meaning. Each of us has a spiritual side; some express it through religion, some in other ways.

But when faced with life-threatening illness, many experience feelings of fear, powerlessness, helplessness and despair, which are often expressions of spiritual distress. Hospice spiritual care counselors are knowledgeable about a wide range of religious and spiritual traditions. They may be a presence in the home, or they may be the connection to the patient’s own faith tradition.

A Pathways Hospice Spiritual Care Story

Years ago, Pathways had a Vietnamese patient who had emigrated after the Viet Name war, in which he was an army colonel. His cancer pain was never seemed completely managed, despite multiple approaches.

One day he mentioned he wished he had not stopped practicing his Buddhism and wanted to pray with priest, however he was too weak to leave home. A hospice spiritual care counselor began networking until he found a Vietnamese Buddhist nun who came to pray with the patient.

Interestingly, not only did the patient’s anxiety decrease dramatically, but his pain was gone after these visits.

How Spiritual Support Can Help

Some of the many ways that hospice spiritual care counselors can help as requested by the patient or family are by:

Giving unbiased spiritual or religious support for patients or family members
Helping to identify and resolve spiritual concerns affecting the patient or family
Exploring the “meaning of life” questions
Administering sacraments
Caring listening
Contacting clergy or a spiritual leader of a specific faith community for the patient
Exploring ways to prepare for “letting go” of this life in preparation for another
Being another caring presence in times of need or distress

For more information about Pathways Hospice Services, please visit our website at www.pathwayshealth.org or email: info@pathwayshealth.org.