End-of-life care for cancer patients varies widely at Boston-area hospitals – The

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Study says many patients enter hospice care too late

By Deborah Kotz Globe Staff September 05, 2013

Slightly more patients with terminal cancer are getting hospice care during the end of their lives, but they are still entering hospice care too late within days of death finds a new national analysis of Medicare patients conducted by Dartmouth researchers. And many are still dying in hospitals, often hooked to ventilators in an intensive care unit, despite studies showing that most cancer patients prefer to die at home.

The percentage of end-stage cancer patients who died in the hospital decreased from 29 percent on average to 25 percent from 2003 to 2010, but there are huge variations among hospitals: In Massachusetts in 2010, about 13 percent of terminally ill cancer patients treated at North Shore Medical Center in Salem died there compared with 41 percent of those treated at MetroWest Medical Center in Framingham, according to the analysis released Wednesday from the Dartmouth Atlas Project .

The project researchers receive funding from nonprofit groups to determine how medical resources are distributed and used in the United States. In the analysis, they also found that the percentage of cancer patients receiving hospice care rose nationwide from an average of 55 percent to 61 percent.

These trends can be called encouraging, but most of the hospice care received was within the last three days of life, said Dr. David Goodman, lead author of the report. What s more, the average number of days patients spent in the intensive care unit during the last month of life increased by 21 percent, which Goodman said could be driven by hospitals looking for more generous insurance payments for expensive services.

Massachusetts hospitals also had large differences in their utilization of ICU services during a patient s last month of life: A patient treated at Cape Cod Hospital spent two to three hours on average in the ICU compared with two to three days for someone treated at Lahey Clinic.

Graphic: Hospital outcomes for terminal cancer patients

There is no evidence anywhere that these variations are due to patients at these different hospitals having different preferences for their end-of-life care, said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center.

Even among teaching hospitals differences existed in the approach to caring for terminally ill patients, with fewer than 20 percent of patients dying in hospitals such as Maine Medical Center and Dartmouth-Hitchcock, while more than 30 percent died in Boston Medical Center and Beth Israel Deaconess.

I d like to think we do better than most places, Forrow said of Beth Israel Deaconess, but we don t do remotely as well as we should.

His institution is beginning a program to ask all patients about their end-of-life preferences and to insert that information into their electronic health record so it s easily accessible to any physician treating them.

Dr. Susan Block, chairwoman of psychosocial oncology and palliative care at Dana-Farber Cancer Institute, said it s vital for doctors to have such conversations with patients preferably when initially diagnosed with a terminal illness.

Patient goals should be the biggest determiner of care and these goals should be set early enough in the illness process that patients can have the kind of ending that they want, she said.

Far too often, doctors do not bring up the delicate issue of dying until patients are entering their last week or two of life, Block added, sometimes after they ve been hospitalized repeatedly or given aggressive chemotherapy for incurable cancers.

Dana-Farber had 29 percent of its terminal patients dying in the hospital in 2010, which was above the national average.

Nearly 60 percent of its patients were admitted to the hospital during the last month of life, and 24 percent wound up in the ICU.

About 56 percent of terminal patients at Dana-Farber were enrolled in hospice care, spending an average of nine days there.

To improve those statistics, the cancer center has been testing a communication checklist that oncologists can use to have end-of-life care conversations with patients.

We re trying to measure whether these checklists will have an impact on providing patients with the kind of care they want at the end of their lives, Block said.

Much of the success will probably depend on doctors having more truthful conversations about just how effective or ineffective aggressive treatments are for metastatic cancer.

In a study published last year in the New England Journal of Medicine. Dana-Farber researchers found that 70 percent of patients with end-stage lung cancer in a national sample and 80 percent of those with terminal colorectal cancer did not report understanding that the chemotherapy they were receiving was unlikely to be curative.

We re not doing as good a job as we should be in helping patients make informed choices, Forrow said.





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To learn about job opportunities with LifeCare, please search our job board. To learn more about our hospitals, click on any location on the map below.

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RA and Lung Disease: What You Need to Know

Besides the joints, the inflammatory process that underlies rheumatoid arthritis (RA) also affects other parts of the body, including lungs, skin, eyes, digestive system, heart and blood vessels. RA-related lung complications are the most common extra-articular ( outside of the joints ) manifestations of RA and include pulmonary nodules (small growths in the lungs); pleural effusion (a buildup of fluid between the lung and chest wall); bronchiectasis (damage to the airways); and interstitial lung disease (ILD).

In fact, it is estimated that 1 in 10 people with rheumatoid arthritis will develop ILD over the course of their disease, making it as deadly among people with RA as congestive heart failure.

What Is Interstitial Lung Disease?

Interstitial lung disease refers to a group of disorders characterized by inflammation and scarring of the lung tissue. In the case of RA-associated ILD, the scarring is caused when the over-active immune system attacks the lungs. When the scarring builds up over time, breathing becomes difficult, and patients may need lung transplants to regain function.

Risk Factors for Interstitial Lung Disease

The risk of developing lung disease is eight times higher in people with RA than in the general population. However, most people with RA are not affected. Risk factors for ILD include:

  • Smoking. People with RA who smoke are more likely to develop ILD.

Higher RA disease activity. High levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptides (antiCCP) antibodies substances that are indicative of more active disease increase the risk for development of ILD.

Older age at diagnosis. People who are diagnosed with rheumatoid arthritis after age 60 are more likely to develop ILD.

Male Gender. Men with RA have a two-to-three times higher risk of developing ILD than women.

Treatment with methotrexate and other DMARDs. Several DMARDs, including methotrexate, leflunomide and azathioprine, as well as biologics, particularly tumor necrosis factor (TNF) inhibitors, have been associated with RA-ILD, according to a literature review published in the April 2014 issue of Seminars in Arthritis and Rheumatism. But Dr. Teng Moua, a pulmonologist specializing in ILD at the Mayo Clinic in Rochester, Minn. says the risk of methotrexate-induced lung injury is less than 1 percent and is reversible once the drug is stopped. According to Dr. Moua, the benefits of methotrexate far outweigh its risks. However, methotrexate is not recommended for people with existing ILD or RA-ILD by the American College of Rheumatology in their 2012 guidelines.

Diagnosis of Interstitial Lung Disease

It is challenging to catch ILD early because it doesn t cause any specific symptoms. Once shortness of breath and dry cough develop, the disease has probably already progressed.

The diagnostic process includes a comprehensive clinical exam, X-rays and lung function tests. If there are risk factors for ILD or abnormal X-ray findings, your doctor will likely perform a high resolution CT.

Treatment of Interstitial Lung Disease

Interstitial lung disease is hard to treat and has a high mortality rate. According to a 2010 study published in the journal Arthritis Rheumatism. once ILD was diagnosed, the average survival in patients with RA was 2.6 years.

People diagnosed with ILD in its early stages can be helped with medication such as corticosteroids and immunosuppressants and put on the waiting list for a lung transplant sooner. However, these treatments don t work for everyone. The best approach is to treat the underlying RA, although ILD may get worse despite well controlled arthritis.

Future Direction in Interstitial Lung Disease

Researchers say an important task for the medical community is to understand the mechanisms behind the development of ILD in people with RA. More detailed knowledge of these processes may one day open doors to better treatments.

Also needed are comprehensive guidelines for screening and diagnosing ILD in at-risk patients so they can be found and treated earlier.

How Can You Protect Your Lungs?

Don t smoke. Get flu and pneumonia vaccines (but always check with your doctor before getting any vaccinations). If you re taking immunosuppressant medications for your RA, you may be at a higher risk for illnesses like the flu and pneumonia, which may cause further lung-related complications. Have regular check-ups, so your doctor can monitor your lungs regularly. Tell your doctor if you have shortness of breath or dry cough right away.

Updated May 2015

Want to read more? Subscribe Now to Arthritis Today !


Interstitial Lung Disease Arthritis #interstitial #lung #disease #rheumatoid #arthritis, #ild, #ra, #ild


#

RA and Lung Disease: What You Need to Know

Besides the joints, the inflammatory process that underlies rheumatoid arthritis (RA) also affects other parts of the body, including lungs, skin, eyes, digestive system, heart and blood vessels. RA-related lung complications are the most common extra-articular ( outside of the joints ) manifestations of RA and include pulmonary nodules (small growths in the lungs); pleural effusion (a buildup of fluid between the lung and chest wall); bronchiectasis (damage to the airways); and interstitial lung disease (ILD).

In fact, it is estimated that 1 in 10 people with rheumatoid arthritis will develop ILD over the course of their disease, making it as deadly among people with RA as congestive heart failure.

What Is Interstitial Lung Disease?

Interstitial lung disease refers to a group of disorders characterized by inflammation and scarring of the lung tissue. In the case of RA-associated ILD, the scarring is caused when the over-active immune system attacks the lungs. When the scarring builds up over time, breathing becomes difficult, and patients may need lung transplants to regain function.

Risk Factors for Interstitial Lung Disease

The risk of developing lung disease is eight times higher in people with RA than in the general population. However, most people with RA are not affected. Risk factors for ILD include:

  • Smoking. People with RA who smoke are more likely to develop ILD.

Higher RA disease activity. High levels of rheumatoid factor (RF) and anti-cyclic citrullinated peptides (antiCCP) antibodies substances that are indicative of more active disease increase the risk for development of ILD.

Older age at diagnosis. People who are diagnosed with rheumatoid arthritis after age 60 are more likely to develop ILD.

Male Gender. Men with RA have a two-to-three times higher risk of developing ILD than women.

Treatment with methotrexate and other DMARDs. Several DMARDs, including methotrexate, leflunomide and azathioprine, as well as biologics, particularly tumor necrosis factor (TNF) inhibitors, have been associated with RA-ILD, according to a literature review published in the April 2014 issue of Seminars in Arthritis and Rheumatism. But Dr. Teng Moua, a pulmonologist specializing in ILD at the Mayo Clinic in Rochester, Minn. says the risk of methotrexate-induced lung injury is less than 1 percent and is reversible once the drug is stopped. According to Dr. Moua, the benefits of methotrexate far outweigh its risks. However, methotrexate is not recommended for people with existing ILD or RA-ILD by the American College of Rheumatology in their 2012 guidelines.

Diagnosis of Interstitial Lung Disease

It is challenging to catch ILD early because it doesn t cause any specific symptoms. Once shortness of breath and dry cough develop, the disease has probably already progressed.

The diagnostic process includes a comprehensive clinical exam, X-rays and lung function tests. If there are risk factors for ILD or abnormal X-ray findings, your doctor will likely perform a high resolution CT.

Treatment of Interstitial Lung Disease

Interstitial lung disease is hard to treat and has a high mortality rate. According to a 2010 study published in the journal Arthritis Rheumatism. once ILD was diagnosed, the average survival in patients with RA was 2.6 years.

People diagnosed with ILD in its early stages can be helped with medication such as corticosteroids and immunosuppressants and put on the waiting list for a lung transplant sooner. However, these treatments don t work for everyone. The best approach is to treat the underlying RA, although ILD may get worse despite well controlled arthritis.

Future Direction in Interstitial Lung Disease

Researchers say an important task for the medical community is to understand the mechanisms behind the development of ILD in people with RA. More detailed knowledge of these processes may one day open doors to better treatments.

Also needed are comprehensive guidelines for screening and diagnosing ILD in at-risk patients so they can be found and treated earlier.

How Can You Protect Your Lungs?

Don t smoke. Get flu and pneumonia vaccines (but always check with your doctor before getting any vaccinations). If you re taking immunosuppressant medications for your RA, you may be at a higher risk for illnesses like the flu and pneumonia, which may cause further lung-related complications. Have regular check-ups, so your doctor can monitor your lungs regularly. Tell your doctor if you have shortness of breath or dry cough right away.

Updated May 2015

Want to read more? Subscribe Now to Arthritis Today !


End-of-life care for cancer patients varies widely at Boston-area hospitals – The

#beth israel hospice

#

Based on what you ve read recently, you might be interested in theses stories

Are Clinton’s memory lapses a health issue, or just dishonest dodging?

Dan Shaughnessy: The hate is for real, and so are the Patriots

Red Sox take over sole possession of first in AL East

Clinton, Trump showcase widely different leadership styles at forum

99 cents a week for the first 4 weeks

Subscribe Subscribe

Save 50% off the regular rate

Study says many patients enter hospice care too late

By Deborah Kotz Globe Staff September 05, 2013

Slightly more patients with terminal cancer are getting hospice care during the end of their lives, but they are still entering hospice care too late within days of death finds a new national analysis of Medicare patients conducted by Dartmouth researchers. And many are still dying in hospitals, often hooked to ventilators in an intensive care unit, despite studies showing that most cancer patients prefer to die at home.

The percentage of end-stage cancer patients who died in the hospital decreased from 29 percent on average to 25 percent from 2003 to 2010, but there are huge variations among hospitals: In Massachusetts in 2010, about 13 percent of terminally ill cancer patients treated at North Shore Medical Center in Salem died there compared with 41 percent of those treated at MetroWest Medical Center in Framingham, according to the analysis released Wednesday from the Dartmouth Atlas Project .

The project researchers receive funding from nonprofit groups to determine how medical resources are distributed and used in the United States. In the analysis, they also found that the percentage of cancer patients receiving hospice care rose nationwide from an average of 55 percent to 61 percent.

These trends can be called encouraging, but most of the hospice care received was within the last three days of life, said Dr. David Goodman, lead author of the report. What s more, the average number of days patients spent in the intensive care unit during the last month of life increased by 21 percent, which Goodman said could be driven by hospitals looking for more generous insurance payments for expensive services.

Massachusetts hospitals also had large differences in their utilization of ICU services during a patient s last month of life: A patient treated at Cape Cod Hospital spent two to three hours on average in the ICU compared with two to three days for someone treated at Lahey Clinic.

Graphic: Hospital outcomes for terminal cancer patients

There is no evidence anywhere that these variations are due to patients at these different hospitals having different preferences for their end-of-life care, said Dr. Lachlan Forrow, director of the ethics and palliative care programs at Beth Israel Deaconess Medical Center.

Even among teaching hospitals differences existed in the approach to caring for terminally ill patients, with fewer than 20 percent of patients dying in hospitals such as Maine Medical Center and Dartmouth-Hitchcock, while more than 30 percent died in Boston Medical Center and Beth Israel Deaconess.

I d like to think we do better than most places, Forrow said of Beth Israel Deaconess, but we don t do remotely as well as we should.

His institution is beginning a program to ask all patients about their end-of-life preferences and to insert that information into their electronic health record so it s easily accessible to any physician treating them.

Dr. Susan Block, chairwoman of psychosocial oncology and palliative care at Dana-Farber Cancer Institute, said it s vital for doctors to have such conversations with patients preferably when initially diagnosed with a terminal illness.

Patient goals should be the biggest determiner of care and these goals should be set early enough in the illness process that patients can have the kind of ending that they want, she said.

Far too often, doctors do not bring up the delicate issue of dying until patients are entering their last week or two of life, Block added, sometimes after they ve been hospitalized repeatedly or given aggressive chemotherapy for incurable cancers.

Dana-Farber had 29 percent of its terminal patients dying in the hospital in 2010, which was above the national average.

Nearly 60 percent of its patients were admitted to the hospital during the last month of life, and 24 percent wound up in the ICU.

About 56 percent of terminal patients at Dana-Farber were enrolled in hospice care, spending an average of nine days there.

To improve those statistics, the cancer center has been testing a communication checklist that oncologists can use to have end-of-life care conversations with patients.

We re trying to measure whether these checklists will have an impact on providing patients with the kind of care they want at the end of their lives, Block said.

Much of the success will probably depend on doctors having more truthful conversations about just how effective or ineffective aggressive treatments are for metastatic cancer.

In a study published last year in the New England Journal of Medicine. Dana-Farber researchers found that 70 percent of patients with end-stage lung cancer in a national sample and 80 percent of those with terminal colorectal cancer did not report understanding that the chemotherapy they were receiving was unlikely to be curative.

We re not doing as good a job as we should be in helping patients make informed choices, Forrow said.





Calvary Hospital Hospice – Hospitals – Lutheran Augustan Center Extended Care –

#calvary hospice

#

Calvary Hospital Hospice

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