Journal of palliative medicine
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The last days of life for a substantial proportion of dying older adults are spent in nursing homes. Considering this, the provision of Medicare hospice care in nursing homes would appear to be an equitable use of Medicare expenditures as well as a valid investment in improving the quality of life for dying nursing home residents. However, government concerns regarding possible abuse of the hospice benefit in nursing homes, as well as suggestion that the payment for the benefit in nursing homes may be excessive, has perhaps slowed the adoption of hospice services into the nursing home setting. ⋯ Still, more research is needed, particularly research focusing on the government costs associated with the provision of hospice care in nursing homes. If subsequent research continues to support the "added value" of hospice care in nursing homes and at the same or less total costs, the issue of foremost concern becomes how equitable access to Medicare hospice care in nursing homes can be achieved. Access may be increased to some extent by changing government policies, and conflicting regulations and interpretive guidelines, so they support and encourage the nursing home/hospice collaboration.
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Deficiencies in education about end-of-life care are widely recognized, both in the "formal" or structured curriculum, and in the "informal" curriculum (the culture in which students are immersed as they learn medicine). Numerous approaches to addressing these deficiencies have been identified. These approaches include developing palliative care leaders; improving curricula; creating standards and a process for certification of competence; creating and enhancing educational resources for end-of-life education; faculty development; growing palliative care clinical programs as venues for education; textbook revision; and creating palliative care fellowship training opportunities. Current efforts in these areas are reviewed, and barriers to their implementation are highlighted.
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In recent years a better understanding of the pharmacologic and pharmacokinetic properties of methadone, including equianalgesic ratios has led to its increased use as a second line opioid for the treatment of pain in patients with cancer. Methadone may be an important alternative for those who have side effects related to the use of other opioids because it has no known active metabolites, is well absorbed by oral and rectal routes, and also has the advantage of very low cost. ⋯ Future research should address the use of methadone as a first-line agent in the management of cancer pain, its use in patients with neuropathic pain, and in those who develop rapid tolerance to other opioids. In some patients with cancer the long half-life of methadone offers the advantage of extended dosing intervals to 12 and even 24 hours, further research is also needed in this area.
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A working group on teaching palliative care in the home was convened at The National Consensus Conference on Medical Education for Care Near the End of Life. Our consensus statement includes: (1) a justification for education in the home; (2) general guidelines about teaching palliative care at this site; (3) identification of major barriers to training in the home, and some suggestions for overcoming these barriers; and (4) specific suggestions about how and what to teach. We find that the home is an excellent site for training in comprehensive palliative medicine. ⋯ Trainees should learn the potential benefits and difficulties of managing terminal illness in the community, appreciate the role of health care teams in assuring safe, secure, high-quality care, and acquire the special knowledge, skills, and attitudes required for providing state-of-the-art palliative care for patients and families facing a terminal illness in the home, including for those dying at home. Instituting education in the home setting will require faculty development, support for more home visiting by physicians, and supervision of trainees in the home by other members of the health care team. Academic medical centers and hospice/home health agencies should collaborate to develop effective training programs.