Research at Hospice of the Bluegrass

Developing a successful palliative care service in an acute care setting.

Ross K, Mathis S, Brockopp D.
J Nurs Adm. 2008 Jun;38(6):282-6.

Hospitalized patients with chronic illness require the same aggressive symptom management as those of hospice patients. Unfortunately, many individuals with chronic conditions require aggressive symptom management but they are not candidates for hospice admission. The authors discuss a palliative care service developed in a 371-bed community hospital to address this need. This consult service has improved patient care without draining hospital resources.

End-of-life care and social work education: what do students need to know?.
Huff MB, Weisenfluh S, Murphy M, Black PJ.
J Gerontol Soc Work. 2006;48(1-2):219-31.

Social workers are major service providers to people who are facing end-of-life issues including the terminally ill and their families. Yet, exemplary models for social work education and intervention methods are limited in rural states. A statewide survey conducted in Kentucky found only two social work courses dedicated to end-of-life care currently being offered by accredited undergraduate and graduate institutions. Another statewide survey found that many hospice social workers are relatively inexperienced and have a need and desire for more education on death, dying and loss. Also, unique cultural, economic and geographic areas, such as Appalachia are enigmas when it comes to the provision of end-of-life care. This partnership provides a varied perspective on delivery of end-of-life care services with an emphasis on social work interventions and education

Is there a model for demonstrating a beneficial financial impact of initiating a palliative care program by an existing hospice program?
Passik SD, Ruggles C, Brown G, Snapp J, Swinford S, Gutgsell T, Kirsh KL. Palliat Support Care. 2004Dec;2(4):419-23

The value of integrating palliative with curative modes of care earlier in the course of disease for people with life threatening illnesses is well recognized. Whereas the now outdated model of waiting for people to be actively dying before initiating palliative care has been clearly discredited on clinical grounds, how a better integration of modes of care can be achieved, financed and sustained is an ongoing challenge for the health care system in general as well as for specific institutions. When the initiative comes from a hospital or academic medical center, which may, for example, begin a palliative care consultation service, financial benefits have been well documented. These palliative care services survive mainly by tracking cost savings that can be realized in a number of ways around a medical center. We tried to pilot 3 simple models of potential cost savings afforded to hospice by initiating a palliative care program. We found that simple models cannot capture this benefit (if it in fact exists). By adding palliative care, hospice, while no doubt improving and streamlining care, is also taking on more complex patients (higher drug costs, shorter length of stay, more outpatient, emergency room and physician visits). Indeed, the hospice was absorbing the losses associated with having the palliative care program. We suggest that an avenue for future exploration is whether partnering between hospitals and hospice programs can defray some of the costs incurred by the palliative care program (that might otherwise be passed on to hospice) in anticipation of cost savings. We end with a series of questions: Are there financial benefits? Can they be modeled and quantified? Is this a dilemma for hospice programs wanting to improve the quality of care but who are not able on their own to finance it?

A pilot study of the impact of a grief camp for children.
Nabors L, Ohms M, Buchanan N, Kirsh KL, Nash T, Passik SD, Johnson JL, Snapp J, Brown G. Am J Hosp Palliat Care. 2002 Mar-Apr;19(2):129-34.

OBJECTIVE: Research indicates that children benefit from supportive interventions to help them cope with the loss of a loved one. The aim of this pilot study was to evaluate children's perceptions of the effectiveness of a grief camp. METHODS: Semistructured interviews were performed with 18 children who attended a weekend-long grief camp. Children also responded to follow-up interviews via telephone. Their parents also completed surveys before camp began and either after camp ended or at a follow-up evaluation. Data were analyzed using descriptive statistics and content coding to uncover key themes in the interviews. RESULTS: Children reported that art activities helped them to express feelings about their grief and release feelings of sadness and worry related to the death. Parents and children felt that the camp was a positive experience and that the children benefited from being in groups with peers who had also lost family members. SIGNIFICANCE OF RESULTS: Evaluating the impact of grief camps, using practical methods such as the ones for this study, is important, as these camps are becoming more popular interventions. Children and parents may benefit from contact at specified follow-up periods after camp to determine if they would benefit from further therapy. Results also provide evidence of the success of this program, which supports the need for funding these types of interventions.

Hospice staff members' views on conducting end-of-life research.
Kirsh KL, Walker R, Snider S, Weisenfluh S, Brown GM, Passik SD. Palliat Support Care. 2004 Sep;2(3):273-82.

OBJECTIVE: Hospice staff members have concerns about the appropriateness of enrolling terminally ill people in research studies. These concerns can have profound implications for the advancement of palliative and hospice care as they can impede the empirical investigation of interventions for improving the quality of life of patients with advanced disease. This survey study was designed to examine hospice staff attitudes, beliefs, and values about research with their patients and family members. METHODS: This study utilized a cross-sectional, anonymous survey design to measure hospice staff members' beliefs, attitudes, and values. The survey contained questions derived by hospice and palliative care experts from their experience and review of the literature. It was handed out at staff meetings and returned via mail. The survey contained 14 questions and was able to be completed in less than 5 min. RESULTS: A total of 225 participants (56.25% response rate) completed the survey and were included in the data analysis. Hospice staff members were largely supportive about the idea of conducting research with patients and family members (mean agreement of 4.08-4.44 on several perception items about research on a 1-5 scale). They also acknowledged a mixture of being protective of controlling access to patients (52% wanted to be the ones to approach patients) and not having enough time for research (59% either had no time or would be willing to spend no more than 10 min on research). SIGNIFICANCE OF RESULTS: Although many of the opinions derived from the survey appear to indicate a willingness to embrace research in a hospice setting, significant barriers, especially time constraints and protective attitudes, remain. Educational efforts and firsthand involvement in the research process might be a useful first step in attempting to address these barriers and traditionally held beliefs against using hospice patients and families in research.

A prospective study of the pathophysiology and clinical characteristics of pain in a palliative medicine population.
Gutgsell T, Walsh D, Zhukovsky DS, Gonzales F, Lagman R.
Am J Hosp Palliat Care. 2003 Mar-Apr;20(2):140-8.

Comprehensive pain evaluation is requisite for optimal management. Few studies have evaluated pain syndromes and adequacy of associated analgesic regimens in one population. Available studies in cancer populations have focused on ambulatory patients or hospice-type inpatients. This study was designed to evaluate multiple characteristics of pain and adequacy of therapy in a broad spectrum of patients with advanced cancer presenting to a palliative medicine service. One hundred pain patients (95 with cancer) underwent a comprehensive pain evaluation consisting of history, physical examination, review of available diagnostics, and a pain assessment tool designed for routine clinical use. Seventy-one percent of 141 evaluable patients reported pain in the month before referral. In these 100 patients, 158 distinct sites of pain were reported, with 88 percent reporting a maximum of 2. Pain due to tumor was the most common cause (68 percent), and the most common pathophysiologic mechanism, somatic (52 percent). Pain was almost equally divided between continuous (48 percent) and intermittent (52 percent). Breakthrough pain occurred in 75 percent of continuous pains. Of these, 30 percent were exclusively incidental, 26percent nonincidental, and 16 percent due to end-of-dose failure. The remainder was of mixed etiology, but almost always with an incidental component. Of intermittent pain syndromes, 61 percent were incidental. On referral, analgesic dosing was inadequate and was compounded by use of regimens that typically did not meet peer-reviewed guidelines. Comprehensive studies rigorously evaluating characteristics of pain and response to treatment are a necessary first step toward more effective treatments for difficult pain syndromes.