Central Vermont:
Central Vermont Medical Center will initiate a palliative care
consult service with a doctor and a nurse on call on July 1, 2000.
This service will be available for all patients, not just dying
patients. The hospital board of trustees, the medical staff, the
nursing staff and hospice, has endorsed a statement of mission and
principles, including end-of-life care.
Central Vermont also received a
$25,000 grant from the Department of Aging and Disabilities to
establish community-wide consistent pain assessment and management
using scales, tools and protocols, including the pain and symptom
management protocol developed by the ExCEL task force.
Central Vermont is still experiencing
late referrals to hospice, at the very end of life. They are working
to communicate to patients, families and health care providers about
the role of hospice and when to make referrals.
Chittenden County:
Barb Segal reported that the FAHC palliative care service has seen
over 600 patients since it opened in 1998. Referrals are made by
house staff and attending physicians and there are ongoing
educational efforts. Referrals continue to increase with 40% from
oncology, 41% from medicine, and relatively few from surgery.
Services provided include facilitating decision making, managing
pain and symptoms, facilitating discharge, ventilator withdrawal,
and facilitating moves from the ICU to a private room or home to
die.
The UVM College of Medicine has
established an elective palliative care rotation for third and
fourth year medical students, and they are working to have it become
a required part of the curriculum.
Veterans Hospital:
The hospital has lost its oncology department and Joe O'Donnell,
M.D. is struggling to provide palliative care with few staff to
help. Patients are being discharged too soon, with too little care.
Mount Ascutney:
Mount Ascutney has a small palliative care team made up of a
physician (Judith Hills, M.D.), social worker (Betsy Burghardt) and
a nursing director. They receive referrals from DHMC and the
community. Mount Ascutney has established a system to review care
after death to determine how to improve care. As in other places
many referrals come too late, even with patients dying in one day or
less.
DHMC:
Bob Santulli, M.D. and Marie Whedon reported on the palliative care
service at DHMC. In January they started an inpatient service with
one nurse practitioner, physicians, VNA, and hospice participating.
Essex/Orleans:
Denise Niemira, MD reported that her area had just received a
$15,000 grant from DAD to institute a palliative care education and
training program and to develop teams in each institution -
hospital, nursing home, and hospice. They conducted a survey of
families to help improve physician education. Their goal is to
create a seamless program of palliative care in all settings in the
community and to identify and train volunteers to sit with people
who are dying.
In connection with the Bill Moyers
program, there will be discussion groups in each community to
provide information about advance directives and to hear and learn
from community members' experiences with death.
Hospice referrals are down and more
physician training is needed.
Grace Cottage:
Bob Backus, MD reported that Grace Cottage is using the pain as a
5th vital sign protocol and the pain ladder that came out of last
year's meeting. They have a hospice room that is part of the new
hospital and a place of tranquility and peace. Physicians need more
education and experience about using the pain ladder.
Rutland:
In Rutland, hospice referrals are late and the length of stay is
short, often less than 24 hours. Hospice is losing money on
pharmaceuticals and supplies. The new medical director of hospice,
Dr. Allan Eisemann is enthusiastic and has good rapport with the
other hospital doctors.
Champlain Valley Hospice:
Champlain Valley Hospice is encouraging patients to use palliative
care along with active treatment. The census is up.
Caledonia:
Tim Thompson, MD reported that Caledonia County is prepared to
request the hospital to approve a palliative care program. The
nursing homes are interested in developing a palliative care system
as well. With institutional support ready to fall into place, the
idea will be to get the program up and running, build it and revise
it as necessary.
Brattleboro:
John Campbell reported on the educational seminar on end of life
care that the Vermont Ethics Network held in Brattleboro in early
June. About 30 people from the hospital, hospice program
nursing-home and AIDS organizations attended the advanced care plan
in training which had a brief clinic on advance directives at the
end. Brattleboro has created a steering committee to get a community
support program up and running for people who need information about
end of life care planning.
Nursing-home administrators and
CEOs:
Marie Kirn reported on the educational program for nursing home
administrators held in late May. Both the administrators and the
CEOs are very interested and want help with developing an
end-of-life care protocol. Marie Kirn and Judith Hills, M.D. plan to
pull together a colloquium in November for all nursing home owners,
CEOs, administrators, etc. There is great interest in education for
the physicians who work with nursing homes.
Follow-up discussion:
Dr. Obbens led a follow-up discussion, which focused on the late
referrals, and short lengths of stay hospices in Vermont were
experiencing. In some cases patients are not ready to accept hospice
treatment. Better communication is needed between specialists end
primary care physicians and physicians and patients. Physicians can
communicate to their patients that hospice offers important benefits
but reassure them that, at the same time, the physician will not
abandon the patient and will continue to follow them and ensure that
they receive appropriate treatment. The Bill Moyers programs may
help get this message across.
June 9th Session
Tim Thompson convened the morning session on Friday, June 9, 2000 by
giving information about the EPEC List Serve.
EPEC List Serve
Tim Thompson reviewed the list serve information. To get on the list
serve address an email to:
EPEC-L@unity.ama-assn.org, type "subscribe" and push send.
ExCEL Happenings
Tim Thompson reports that the VMS/ExCEL list serve is up and
running. He asks if there is a way to reach physicians about this
program and the list serve. If anyone knows of anyone who may be or
would be interested let Stephanie Lane at the VMS know. To join the
list serve call Stephanie Lane or Tim Thompson. If you are already
on the list serve type
excel@vtmd.org to send a message to the entire ExCEL list,
approximately 36 people. The VMS web page is also up with a section
for ExCEL. To view this web page go to http://www.vtmd.org and click
on ExCEL.
The Steering Committee has been
meeting monthly and will continue to meet. They meet every other
month in Montpelier and every other month by conference call.
There was discussion by the group
about the focuses for the program. It was decided that there were
three main objectives:
- Palliative Care Project
- Advanced Care Project
- Organization of Care Project
To reach these goals there must be
collaboration. We can do this by:
- Having statewide meetings every 6
months
- Utilizing the list serve
- Placing information on the web
page
We must also figure out what
collaboration is being done and build on it.
Task Forces (Future Task Forces)
Symptom Relief Guidelines:
Diana Peirce reported on work that had been done on the symptom
relief guidelines. She stated that these guidelines had been worked
and re-worked for years and had started with a small subgroup of
physicians and nurses.
Central Vermont Medical Center has
now set these guidelines into standing orders to use in the
hospital. They were presented to the medical staff and were
approved. These guidelines could also be used in nursing homes.
Perhaps, if we identified palliative
patients, the standing order could be placed on their chart then the
physician could use it as a checklist.
There was concern within the group
that there wasn't enough interaction between physicians and nurses.
Diana voiced that it was working in Central Vermont, but that there
was some concern that there may be friction between physicians and
nurses and that needs to be looked at. The group discussed the
differences between hospitals and hospice nurses. The consensus was
that hospitals are about preservation of life at all costs and
hospice was about comfort at all costs.
Tim Thompson shared with the group
that when he brings these guidelines to his hospital he is going to
add these things:
- In chronic opiate tolerant
patients that come in with new pain, give them pain meds at higher
doses until they are comfortable and you won't kill them.
- Need to build in mechanism to keep
current and for renewal.
The group felt comfortable to take
the guidelines back to their local hospitals. Tim asked that they
report back and give feedback on the response of the hospital. Diana
Peirce and Marilyn Hart, M.D. said that the copy of the guidelines
that was given to the group was too long and can be revised as
people wish for their hospitals.
Diana Peirce would like to begin a
new task force dealing with palliative care in the hospital. The new
members that volunteered are: Diana Peirce, Barb Segal, Marilyn
Hart, Jim Hunt, Sandra Filleut, Zail Berry, Karen Skalla, Denise
Niemira, Betsy Burghardt, Judy Hills, Patti Kent and Allan Eisemann
Mission Statements:
Tim Thompson conveyed the idea that we should let the hospitals know
that a list of the hospitals with mission statements that include
palliative care will be listed in the next VPQHC Quality report, as
a challenge for them to revise their own.
It is believed that this project of
revising hospital mission statements will be seen as being needed
community wide. The elements needed to accomplish this are 1)
palliative care skills, and 2) public education.
How can we nourish incipient groups:
- Need to provide money
- Provide models to build on and
adopt
- Need to have local leaders
Brattleboro: Next Step
At the last meeting it was decided that a steering committee needed
to be formed. The members of this committee will then decide what
the next step is and will call on VEN & ExCEL. This process will
take time, at least three years according to Dr. Golodetz.
CVMC - Will integrate the palliative
care statement into it's own. Northwestern - Planning to begin a
palliative care service
- Is going to have a palliative care nurse
- The Hospice program is really on the upswing
Middlebury - Has been doing a lot of work
Rutland - Dr. Eismann has nurses who are very in tune with what
hospice is doing.
Tim suggests that we get in touch
with local people and see who is ready to go and what has been done
in their areas. He also suggests that included in the letter are the
names of the six palliative care certified physicians, to show that
people are getting certified and doing something.
AAHPM Certifications:
There are 6 certified physicians in Vermont and a whole other list
of people working in the field of palliative care. This shows that
obviously people are working in palliative care and are doing well.
We should contact hospital directors and express the need for
physicians/palliative care workers to be certified.
Possibility -Work this need into
hospital mission statements.
- Hospitals pay for certification.
We need to use the Hospice &
Palliative Care Council as a forum to get collaboration for support.
Marie Kirn at Gifford Hospital is
trying to create joint positions for a part-time palliative care
nurse.
Quality Standard of End-Of-Life Care:
Laurie Waite from the Vermont Program
for Quality Health Care reported on the piece that is to be included
in the Quality report that VPQHC puts out annually. Anyone who wants
to get on the mailing list can. She asks that if you have any
comments or ideas for future articles you contact her at
laurie.waite@vpqhc.org. VPQ is a private non-profit organization
and is recognized by the Vermont Legislature as having peer review
protection. VPQ is a group of practitioners who come together to
develop quality standards and health care programs.
The Quality report (an excerpt of
which was included in the information packet): VPQ is very proud to
be able to include the end-of-life care spotlight in the Quality
report and will continue to work on end-of-life care issues.
End-of-life care will be included every year in VPQ's Quality
Report. Laurie asks that we start thinking about what should be
included next year. Quick brainstorming of the group comes up with
1) results of the DAD grant (next year or year after) 2) list of
board-certified physicians and nurses and where they are from, and
3) regional breakdowns of stats and information. VPQ will ask for
data you want to be included in October and November. Information
needs to be provided to VPQHC January - March. There may be a
representative from ExCEL who will be in on the whole Quality
report.
There is a standing offer from
Medicaid to get a list of medications for each Medicaid patient;
they have a database of medications for each Medicaid patient. This
could tell us how people are using their pain medications. The
question is, how would physicians feel about that. Ginny relays that
Cy Jordan suggested looking at routes of medications rather than
types.
At the next meeting we need to have
names of board certified people in the area.
On Task Force: Denise Niemira, Joe
O'Donnell, Ginny Fry and Cy Jordan
EMS DNR:
Diana Peirce and John Campbell have met with the State Health
Department and their lawyer twice and they have said that if DNR
were going to be honored by EMS the patients' physician would have
to deem them terminally ill. At these meetings it was arrived at
that there is a need to have DNR in the home. Diana and John are
developing another document that will clearly indicate the patients'
wishes. If the patient is home care or hospice then they must be
involved. There will be one more meeting with the Department of
Health.
In order for people to feel
comfortable their needs to be communication and support
This protocol will enable terminally
ill patients to decline CPR. It will also clarify that a patient
does not have to be terminally ill to deny care.
A concern is raised about the word
rescucitation, needing better definition. Because some feel that
rescucitation means fluids, "other rescucitation measures" should be
changed to "if cardio pulmonary arrest. There is discussion about
this, but there is consensus that the definition is spelled out
clearly.
Hospitals, hospices and nursing homes
need to discuss this protocol with patients and potential patients.
The importance of this protocol needs to be communicated to all
involved. This should be added to the cover letter.
On Task Force: John Campbell, Diana
Peirce, Madeleine Mongan, Jeff Bell, Dan Manz, Mary Shriver, ?
AMA EPEC Training at Hospitals:
Tim discussed the training that will be happening in St. Johnsbury
late this summer. If anyone is interested in the source materials
you can either get them from the web page or from Tim, Zail or
Marie. Soon the "laundry list" of materials that are available will
be available.
EPEC Physicians in Vermont are: Tim
Thompson, Arnold Golodetz (went to the training), Judy Hills and
Zail Berry (has the materials)
Committee: Tim Thomspon, Arnold
Golodetz, Chris Allen and Zail Berry
Vermont Ethics Network Meeting:
John Campbell reports on the plans for a November Conference. There
is no agenda yet as the planning group has not met, but they will
soon. The meeting in Central Vermont will be piggybacked with the
EPEC training.
Patrick Flood is interested in
co-sponsoring/planning a conference with a speaker - 1 day plus
dinner.
VMS will help coordinate this with
Tim and VEN.
Other Business:
On Wednesday October 18, 2000 the Hospice of New Hampshire Annual
Conference on Pain Management will take place in Portsmouth, New
Hampshire.
Excellent Care at the End-of-Life.
Arnold suggests that "at the" be changed to "near" and John Campbell
suggests "for". The group discusses the two possibilities and agrees
on "for". New name: Excellent Care for End-Of-Life.
Stephanie Lane (VMS) has offered to
design our letterhead/Logo for the three groups.
Madeleine will be setting up the next
meeting of ExCEL for sometime in July.
New Task Forces Formed at the
Meeting
Task Force:
Palliative Care in the Hospital |
Members:
Diana Peirce, Barb Segal, Marylin Hart, Jim Hunt, Sandra Filleut,
Zail Berry, Karen Skalla, Denise Niemira, Betsy Burghardt, Judy
Hills, Patti Kent and Allan Eisemann |
Task Force:
Quality Standards for End-of-Life Care |
Members:
Denise Niemira, Joe O'Donnel, Ginny Fry and Cy Jordan |
Task Force:
AMA EPEC Training |
Members:
Tim Thompson, Arnold Golodetz, Chris Allen and Zail Berry |
Task Force:
Mission Statements |
Members:
Tim Thompson, Arnold Golodetz, Madeleine Mongan, Marie Kirn |
Task Force:
AAHPM Certification |
Members:
Undetermined |
Task Force:
EMS-DNR |
Members:
Diana Peirce, John Cambell, Madeleine Mongan, Jeff Bell, Dan
Manz, Mary Shriver, ? |
|
