News From the End of Life

Health system requires info from advance directives

Policy aims to prevent confusion among family

Dying patients who have advance directives and are seeking care in the Owensboro (KY) Mercy Health System will now be required to include details of their advance directives on a form until the actual advance directive can be produced.

This revision in the health system’s policy is aimed at preventing confusion from arising when families disagree among themselves over treatment decisions, which could result in provision of care that is against the patient’s wishes, Owensboro Mercy Health System officials say.

"Sometimes unexpected things happen, and you have a situation where all the siblings aren’t agreeing with how to deal with the parent’s illness," says Lisa Jones, vice president of patient services. "It gives us a consistent place to go to find out exactly what the patient wants."

In addition to stating what medical treatment the patient wants, such as resuscitation, nutrition, and hydration, the advance directives may name someone to make decisions about treatment if the patient is unable to do so. As long as the patient is able to give informed consent, advance directives will not be used. They also can be changed at any time.

In the event a patient is admitted who has advance directives but didn’t bring them, the patient will be given a form to list instructions contained on the advance directive. The form, signed in the presence of a witness, instructs the hospital to carry out the orders until the original directives are brought in. The form also allows patients to name someone to make decisions concerning medical treatment and gives permission to donate organs.

Study: Don’t cut back on social work services

Increase in social services results in lower costs

As hospices try to scale back their costs, some may find that cutting back on social work is an easy place to save money. But according to a University of Arkansas study, those same hospices may be setting themselves up for a financial loss.

"The original vision for hospice consisted of
an interdisciplinary team of professionals who would make visits to the home to provide not only for the patient’s physical needs but also to offer social services and psychological and spiritual counseling," said Dona Reese, assistant professor of social work at the University of Arkansas in Fayetteville. "But across the country, we’ve seen the nonmedical services — including social work services — minimized under the rationale that it’s more important to provide for the patient’s physical needs."

In addition, the national study of hospice programs shows that providing adequate social work services in conjunction with physical care significantly reduces overall hospice costs. Additional benefits include fewer hospitalizations for the patient, decreased nursing costs, and higher client satisfaction.

Taking a random, stratified sample from the membership of the National Hospice and Palliative Care Organization in Alexandria, VA, the study assessed 66 home hospice programs and examined 330 individual patient cases. Initial findings showed that nurses outnumbered social workers three to one in the average hospice. The researchers also documented five times as many nursing visits as social work visits to each hospice patient.

Participating hospice programs contributed information through three steps. First, the social worker with the greatest experience in hospice filled out a social work questionnaire that described the qualifications of social workers employed at the hospice, the duties of those social workers, the overall functioning of the hospice team, and the demographics of the clients they served.

"We collected so much data because we wanted a comprehensive look at how social work services impact hospice outcomes," Reese said. "Knowing exactly how these services benefit hospice programs can help administrators design hospice care so that it fully meets patients’ needs while still being cost-conscious."

A key finding of the study holds that an increase in social work services actually lowers overall hospice costs. This alone constitutes a good reason to stop cutting social work from the protocol, Reese said. But the statistics also revealed specific correlations that prompted researchers to recommend changes that will help hospice programs run more effectively and economically.

For example, the presence of a social worker at the patient’s first interview with hospice representatives contributed to lower hospice costs, lower labor costs, lower home health aide costs, and improved functioning of the hospice team.

According to Reese, early participation provides an opportunity for the social worker to evaluate factors such as family dynamics, social support systems, and personal beliefs, customs, and concerns, among other things. Such information enables the social worker to identify problems that the patient will likely encounter and begin building support networks that will address the problems in a preventive manner.

Funding end-of-life care education for social work

Graduate students will learn care skills

Current social work education does not produce social workers trained in end-of-life care. A new initiative in California is hoping to correct this shortcoming by establishing course work in four Southern California graduate social work programs.

The new initiative will support the development of curriculum to educate graduate social work students about end-of-life care skills in the classroom and in training sites throughout Southern California.

"Neither a well-defined end-of-life care education program nor an end-of-life care specialization in social work exists in our region, and field experience is not available to MSW students," says
W. June Simmons, president and CEO of Partners in Care Foundation in Burbank, CA, one of eight recipients of The Project on Death in America’s Social Work Leadership Development Award. "This project has enormous potential to ease suffering and enhance quality of life through educated social work interventions."

Simmons will lead field work conducted in four social work agencies and eight social/medical service providers representing the area’s enormous ethnic and racial diversity. In addition, the initiative hopes to answer the questions, "Who will care for our aging parents as they approach the end of their lives? How will they be trained? By whom and where?"

Chronically ill patients not getting proper care

A Harris Interactive survey of 1,663 adult Americans has found that Americans fear the 125 million people living with chronic diseases are not getting the care they need. The survey found that:

• 72% of Americans say it is difficult for people living with chronic conditions to get necessary care from their health care providers.

• 74% say it’s difficult to obtain prescription drug medications.

• 89% say it’s difficult to find adequate health insurance.

• 78% say it’s difficult to get help from their own family.

The study also found that nearly two-thirds of those polled who do not currently have a chronic condition believe they will develop one during their lifetime, and they fear that when they do, they will be unable to afford needed medical care and will become a burden to their families. The survey also found that, on average, family caregivers provide care for their loved ones for 4.5 years, with the unpaid help of four friends or family members.

Upper-level hiring in health care looks strong

People looking for executive and professional positions in the health care field should have little trouble finding a job, according to a recent hiring survey conducted by search and recruitment firm Management Recruiters International of Cleveland. The survey reported that 54.3% of health care executives with responsibility for hiring said they plan to increase their staffs in the first half of this year, up 8.5% from the 45.8% level of the second half of 2000.

Another 42.5% of those surveyed said they plan to maintain current staff size, up 10.3% from the second half of 2000, while only 3.2% plan staff decreases, a decline of 18.8% from last year’s second half. Across all industries, 58.8% of hiring executives projected new hires during the current half, 35.2% plan to maintain current levels, and 5.9% plan decreases.

JCAHO releases home care manual

The Joint Commission Resources, a subsidiary of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), has released its 2001-2002 Comprehensive Accreditation Manual for Home Care. The manual is divided into two main sections. The first contains common standards that apply to all types of home care organizations; the second provides specific standards for home health (including personal care and support services), hospice, pharmacy (including home care and long-term care pharmacies and non-physician-based ambulatory infusion centers), and home medical equipment (including respiratory therapy and rehabilitation technology services). Also included are segment-specific standard intent statements, as well as a separate section on compliance tips. Cost for the publication is $225. Cost for an electronic version of the manual and a traditional print version is $550. When ordering, use code CAHC-01XY.

To order, call the Customer Service Center at (630) 792-5800 between 8 a.m. and 5 p.m. Central Time M-F, or go on-line to