Power of Positive Thinking

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

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

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

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

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?

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

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.