Hospice Care versus Palliative Care

As we age, new terms begin to creep into our vocabulary. My exposure to hospice care came into being when my first wife had cancer with little hope of winning the battle. Almost 12 years ago on March 23, 2002, she lost the battle. If it had not been for the caring folks of our local hospice group, I honestly don't know what I would have done. As people with diabetes, we never know when we may need hospice care or palliative care.

Palliative care was not a term I was familiar with until about ten years later. At the time, I was not sure I liked what I saw being done to a friend with Alzheimer's disease. Since I was not sure that there were other illnesses involved, I was concerned that he was being ignored and a form of euthanasia was being employed. One day I asked the nurse why he was being treated the way he was and I was told he was being given palliative care. I won't go into the expletives that went through my mind about his care, but I was going to do some research.

Hospice care and palliative care can go hand-in-hand, and often do, but it is important to understand the meaning and definition of each. Hospice Care is palliative by its very nature. My friend was receiving neither, but was on an experimental treatment, which his family was not aware of and once they were made aware of this, transferred him out of the care facility to another facility.

When most people think of hospice care, they are thinking about end of life care and this would be correct. One point is important - With Hospice Care, Medicare requires that a physician certify that a patient’s condition is terminal. The physician must certify that a patient’s life expectancy is six months or less. Both Palliative and Hospice Care can be delivered at any location. Hospice is normally considered for people near the end of life. Just because they are on hospice does not mean that once the six months of hospice has passed, they are removed from hospice. Many people have been on hospice more than once and many have been on hospice longer than six months.

The focus of hospice relies on the belief that each of us has the right to die pain-free and with dignity, and that our loved ones will receive the necessary support to allow us to do so. Hospice is a philosophy, not a specific place.

1. Hospice focuses on caring, not curing and, in most cases; care is provided in the person's home.
2. Hospice care also is provided in freestanding hospice centers, hospitals, and nursing homes and other long-term care facilities.
3. Hospice services are available to patients of any age, religion, race, or illness.
4. Hospice care is covered under Medicare, Medicaid, most private insurance plans, HMOs, and other managed care organizations.
5. Hospice Care services are more inclusive than Palliative Care services. Hospice Care includes physician services, nursing services, social worker, spiritual care, bereavement care and volunteers.

For a blog on three hospice myths, read this blog.

Palliative care treatments are not limited with palliative care and can range from conservative to aggressive and curative. This can be used at any stage of the illness and need not wait until the advanced stages.

Palliative care focuses on relieving the symptoms that are related to chronic illnesses.

This care is generally provided by a team of specialists, which may include physicians, nonphysician clinicians, social workers, chaplains, pharmacists, and nutritionists. The palliative care team works in conjunction with the primary physician. The team can offer assistance with treatment of pain and other symptoms, assistance with communication of bad news regarding diagnosis and prognosis, support for patients and families in medical decision-making and in navigating the complex medical system, and emotional and spiritual support.

Palliative care in the United States is relatively new starting in 1996 where hospice care started in when the philosophy and principles were introduced in the 1970s. The concept gained acceptance and Medicare began covering its costs in 1982. The first board examination for palliative care under the American Board of Medical Subspecialties (ABMS) was offered in 2008.

Nurses are an integral part of any palliative care treatment. Since palliative care nursing is so complex, the specialty requires training in subjects such as social issues and psychology. Palliative care nurses should have a thorough knowledge of medications used for pain, symptom control, and psychiatric conditions. The nurses work with the patient and bring information to the treating physician, but they also work quite independently.

Substitute Decision Makers

I am starting a topic that should be of concern to everyone and especially if you are elderly. This applies to you regardless of the number of chronic conditions or illnesses you may have or not have. Even the terminology can vary from the title of this blog to Surrogate Decision Makers. I am talking about the person or persons making the decisions for you while you are in the hospital or anywhere you are under medical care and are unable to verbalize your will.

Even if a family member thinks they can speak for you, sometimes it is better that they don't. I would strongly urge readers to read this written by Kathy Kastner, a health educator writing in the Stanford Palliative Journal in March 2012. She covers many ideas I had not even imagined could become important. I have experienced the death of my first wife and thought I could handle most situations. Honestly there are some issues I had not considered.

In reading her article, I realized that there are circumstances we often forget about or we let slide because we aren't ready to talk about the topic or don't foresee this happening. If you think the topics of hospital admissions, emergency hospitalization, medical operations, or possible death scares you, don't wait until it is too late to discuss this with family members, relatives, or close friends that may be called on to make decisions for you. You may discover that the person you thought you trusted is not ready to accept your wishes or has their own agenda for you.

Please don't rely on your doctors to make your decisions. You may be put through more tests and procedures that you don't desire and that are not medically necessary. Many doctors will attempt to bully you or your advocate to get their way.

Once you have had this discussion, put it in writing and make it legal. This will put other people on notice that you want this person, be it spouse, a legal age child of yours, or close friend to carry out your wishes.

A strange incident happened to a trucker friend recently. He was out of state and his wife was involved in an auto accident. The youngest daughter happened to be at their home that day and when the sheriff called, she rushed to the hospital and gave orders about what to do for her mother. This was not the wishes of the mother who had specified that her son or husband be contacted for medical decisions. The hospital ignored the documents that were on file for the mother and proceeded to follow the daughter's instructions. Complications happened on the operating table and the mother died. When the son found out what had happened, he immediately called his father who would be home the next day.

Not only had the daughter disobeyed her mother's wishes, but also her request for cremation. Apparently her mother anticipated what her daughter would do, because when the will was read, it clearly stated that if she had not allowed her brother or father to be present and follow her wishes, she was excluded from the estate. To make matters worse, she lost the lawsuit contesting her mother's will, and her father barred her from the house and told her and her husband not to come again.

I later found out from the father that her accident was not survivable and in the documents his wife had requested that if she died that her organs were to be donated if they were healthy. The daughter would not allow this either, as the doctors had asked. The hospital has already offered a settlement because they did not look at her records or call her doctor as they were ordered to do. Even if they had not looked at her records, they knew they should have called her doctor who would have reminded them about her wishes.

Use Care When Taking Vitamins and Minerals

I have to respect this oncologist when he makes a statement about stopping supplements. This is because when dealing with cancer medications and chemotherapy, many vitamins and minerals can conflict with the cancer medications and cause death.

However, Dr. James Salwitz, then goes on to make some statements that shows he does not understand nutrition. For many younger people what he says is true, but when dealing with the elderly and some chronic diseases, I find his statements lacking in factual information. Dr. Salwitz states, “Let us be clear; in the absence of malnutrition, malabsorption and a few uncommon medical conditions, there is absolutely no reason to take a multivitamin. They do not prevent or fix anything. Originally developed for starving populations and hungry soldiers during the Second World War, they have no place in a society with access to a broad range of foods.”

The key word in the above statements is malabsorption, which often happens in the elderly as they loose the ability to properly digest and absorb the nutrients contained in the foods.

In many other chronic diseases, like diabetes, care must be taken and some supplements can be of value. This is true when metformin is taken for an extended period of time, as older patients often are unable to utilize or absorb the foods that can be used by the body. This is especially true of vitamin B12 although many doctors refuse to test for this deficiency. Vitamin D2 can also be problematic for some elderly people with diabetes.

Wait you say, many foods are vitamin D fortified. True, but they are fortified with vitamin D2, which is not often readily utilized by the body. It is man made and does not stay in the body for the time necessary to be used.

Food Sources for vitamin D:

There are two dietary forms of vitamin D:

1. Cholecalciferol - D3

2. Ergocalciferol - D2

These are naturally found in foods and are added to milk. Not all yogurt and cheese are fortified with vitamin D. Food sources of vitamin D include:

1. Cod liver oil (best source). Cod liver oil often contains very high levels of vitamin A, which can be toxic over time. Ask your health care provider about this source of vitamin D.

2. Fatty fish such as salmon, mackerel, tuna, sardines, herring

3. Vitamin D-fortified milk and cereal

4. Whole eggs – egg whites are not a great source of vitamin D, but the whole egg is. Eating 2 or 3 eggs per day has little effect on cholesterol and actually can aid in cholesterol control.

It is suggested that people in need of vitamin D not go to a doctor for a prescription, as most prescribe D2, which is more expensive and vitamin D3 is on the shelves and is much cheaper.

Harsh, yes. But these errors are serious. Even David Mendosa has told me to be careful not to take vitamin-D2, but to take vitamin-D3. What bothers me is that people will go to the doctor for a vitamin D prescription and pay the doctor fee and a higher cost for vitamin-D2, when vitamin-D3 is on the shelves and a lot cheaper. Vitamin-D2 is much less effective in humans than vitamin-D3. D2 is largely human made and added to foods as a fortifier. Vitamin-D3 is also consumed by consuming animal-based foods. So those on non-meat lifestyles, should have their doctor check their vitamin D levels and consider taking vitamin-D3 supplements.

In addition to having markedly lower potency, D2 also has a significantly shorter duration of action relative to vitamin D3. Both forms of vitamin D produce similar initial rises in serum 25OHD over the first 3 days, but 25OHD continues to rise with D3 supplementation, peaking at 14 days, and serum 25OHD falls rapidly in D2 treated subjects.

I would encourage people, especially people over the age of 65 to be tested for levels of vitamin D. When it comes to ranges for vitamin D, deficiency levels below 15 ng/ml and you should not have levels above 80 ng/dl. Many physicians are happy to have people at 20 to 30 ng/dl range.  This is quite unsatisfactory and many people should be above 50 ng/dl.

Please also read the supplement section of this website for the University of Maryland and the vitamins, minerals, and supplements section of the University of Oregon website. Always check the warning section or the safety/toxicity information. Often there may be sections about conflicts with prescription medications. Read these very carefully. If you still have questions, have a talk with your pharmacist about what vitamins, minerals, and supplements to avoid when taking a prescription. 

The last read I would suggest is this by Jon Barron as he discusses the Institute of Medicine (IOM) and the recommendations they make, which are pathetic.

The Whole Grains Low Fat Crowd

I wonder how many more years we are going to have to suffer, yes, suffer from the teachings of the whole grains and low fat advocates. Thankfully, more people are realizing that their teachings are at the root of our obesity epidemic. Yes, it may take a few more decades to scientifically put these teachings where they belong – in the trashcan.

What started me on this? I happened to watch the program in Iowa Public TV on March 3, when Dr. David Perlmutter was talking about his program for eliminating whole grains from our food plans. He is the author of: The Better Brain Book and the #1 New York Times Bestseller, Grain Brain. He is recognized internationally as a leader in the field of nutritional influences in neurological disorders.

The program is scheduled several more times during the Public TV's campaign to obtain funds from viewers for programs and operations. Since there are no videos available, that I have been able to locate, I can only suggest that if the public TV network in your state is running their fund raising campaign, go to the website for your state ((enter your state) public TV) in your search engine and enter Dr. David Perlmutter in the site's search area. This could help you find the program – whether you contribute is entirely up to you and I am not promoting this.

Dr. Perlmutter clearly states that fat, except Trans fats, is our friend and whole grains are our enemy. He says that in addition to them helping our diabetes epidemic, they also affect many neurological disorders and by eliminating them from our food plans, many neurological problems can be improved or delayed. He listed attention deficit hyperactivity disorder (ADHD) as being helped and in the case of Alzheimer's disease, it could be delayed or greatly improved for some time. He did not promise a cure, but stressed improvements that eliminating gluten created.

He mentioned several other neurological disorders being improved, but I had an interruption and missed the names.

During his talk, he emphasized that the claims of lost nutrients the grain people were warning consumers about could be found in other foods and that their claims were not valid unless people were relying on whole grains entirely.

His books are available on Amazon and the #1 Bestseller can be found at this link. I have spent my allowance for books, but I do intend to obtain his one book later this year.

More Efficient Use of Telemedicine

Dr. Robert Kocher wrote a blog on TheHealth Care Blog site and he explains the need for doctors to be able to practice across state borders. He states that federal standards govern medical training and testing, but the individual states each have their own licensing board, often referred to as a state medical board. The reason he is using is to promote telemedicine, which has had its good on display, but many detractors and many doctors in opposition because they do not want to have telemedicine in their backyard.

I agree with Dr. Kocher, but think he is banging head against the wall. The American Medical Association and many state medical boards are busy lobbying against telemedicine. Until there is more public demand and state legislatures start deciding that telemedicine is needed for their state and pass legislation, I doubt this will happen. In addition most state medical boards do not recognize license reciprocity and want the revenue they can receive.

Now this is only my opinion, but I think many doctors want telemedicine to succeed. I also think until more states adopt in state telemedicine, a national call will not succeed.  The example that I can think of is what has happened in the state of Kansas. The University of Kansas Center for Telemedicine & Telehealth (KUCTT) is a recognized world leader in telehealth services and research. KUCTT is part of the KU Medical Center. The following is from the KUCTT.

“Beginning in 1991 with a single connection to a community in western Kansas, the Kansas telehealth network now has more than 100 sites throughout the state. KU Center for Telemedicine and Telehealth has conducted thousands of clinical consultations for Kansans and hosted hundreds of educational events for health professionals, teachers, students and the public across the network.

KU Center for Telemedicine and Telehealth has been an integral piece of several national and international collaborations that have demonstrated the potential of telehealth to eliminate distance as a barrier to healthcare. With more than 24,000 clinical consultations and educational events, KU Center for Telemedicine and Telehealth is one of the oldest and most successful telehealth programs in the world.”

If other states would use this as a model for their state, then telemedicine would be given a big boost and possibly be ready to take on national importance and then legislatures or Congress might consider new licensing to be able to operate across state borders.

Think of the importance this could have for those of us with diabetes in our own state. What happens when the weather is like this winter when travel is often impossible and blizzard warnings are issued. A medical appointment is probably missed and important information can be withheld from you and the doctor. If telemedicine was available, the appointment might not be a total loss if you had a local doctor on the network that could do the necessary tests or a local hospital where the tests could be done.

I can only hope that more people will consider the suggestion and make telemedicine available to more without having to cross state borders. Then the doors may open for telemedicine nationally.

SGLT2 Inhibitors Seem to Increase Glucose Production

Paradoxes do happen and this is a surprise. Researchers discovered this while studying the newest class of diabetes drugs, sodium glucose cotransporter 2 SGLT2 inhibitors. The result was obtained from dapagliflozin (Farxiga), one of the two FDA approved drugs in the class.

“Although they increase the amount of blood sugar dumped into the urine, the newest class of diabetes drugs appears to increase endogenous (proceeding from within; derived internally) glucose production, two studies found.”

The researchers are wisely calling for additional studies to confirm the results they found. The first study was done at the University of Texas Health Sciences Center in San Antonio and involved 18 men. The second study was done at the University of Pisa in Italy, and used the drug empagliflozin. The Italy study used 66 type 2 patients.

The researchers found that the drugs did what they were designed for; increase the glucose excretion in the urine and lower plasma glucose levels. This is when the researchers discovered the substantially increased endogenous glucose production, which was accompanied by an increase in glucagon levels. Patients on the placebo had no change in these levels.

The researchers reported that the increase in endogenous glucose production offset about half of the amount of glucose dumped into the urine. In other words, if the endogenous glucose production could have been prevented, the decrease in glucose caused by dapagliflozin and empagliflozin would have been about double.

By having others replicate this finding, the researchers are suggesting that clinicians may want to use the SGLT2 inhibitors in tandem with incretin therapies, which have effects on glucagon and could reduce the increase in endogenous glucose production. The researchers then ask for further metabolic studies for verification of this.

This research does point to potential problems for SGLT2 and clinicians need to use caution in prescribing this medication until the full effects are understood. As people with diabetes, I would also urge caution in accepting this medication until the full effects are determined. This is one paradox that may have long-term harmful effects.

Which Hand Is Correct in Diabetes Treatment?

I admit I was horrified when I read this press release. My first thought was what will these people think of next. Nothing about diabetes can be this cut and dried. When I arrived at the image of the hand that the topics assigned to each part, I really was at a loss for understanding.

This image shows the "lend a hand" illustration: an open palm facing out. The five major forms of diabetes interventions are arranged in descending order of importance from thumb to pinky. The order is smoking cessation, blood pressure control, metformin therapy, lipid reduction, and glucose control, respectively.
Image credit: Modified by Heather White, Tufts University

To accomplish each in the order as described, what are they going to do when they have a patient that has never smoked a cigarette? Will they have to have the patient learn to smoke just to have the patient cease smoking? What will they do for the patient that does not have hypertension? Are they going to insist that a person take metformin when the person may be able to manage diabetes with nutrition and exercise? Are they going to force people with normal lipid panels to take statins? Then we arrive at what they consider the least important intervention – glycemic management.

Now granted, the majority of people newly diagnosed with type 2 diabetes will have some of the requirements needing intervention, but why would they not do all at once. I would have hated for them to have done one at a time on me. This does seem to be the recommendation that they suggesting – treating each in the order they have identified until it is under management and then moving to the next digit of the hand. This has me wondering about the conflicts of interest and how much influence this has on their decision.

The senior author lamely admits, "Some degree of glycemic control is necessary to prevent symptoms." "It's just that the return on investment is low when we try to push patients with diabetes to get their blood glucose as close as possible to normal."

It seems to me that the authors are too tied up with return on investment to care about the overall health of the patient. To these authors, I would remind them that health care is not this cut and dried and not every patient will present with the same needs. Yet they seem to be of the opinion that every patient should be treated the same and left no room for adapting their model to fit the patient. Until the medical community stops practicing a “one-size-fits-all” regimen, we as patients need to stay alert to be sure we receive the treatment we need and the explanation of why we need the treatment.

You should read another interpretation of this by Tom Ross when he discusses also using the other hand. I found his blog very interesting.