Abstract
Dear Editor:
How much direction do hospice medical directors provide? A few cases that I have seen over the years as a pain consultant keep nagging me. One was a woman in a nursing home with lung cancer. She was delirious and her pain was allegedly out of control. She was extremely cachectic, bedridden, constantly fidgeting, and on a morphine subcutaneous infusion. It was expected that I would switch her to hydromorphone and start haloperidol. Medical records revealed a solitary lobar lung mass with no evidence of metasteses. Why should she have pain? On a close read of the old medical records (which I had requested and often are not available) I learned that she, her husband, and other family members were alcoholics. The hospice nurse had noted large amounts of alcohol in the home. The patient was started on parenteral thiamine, folate, multivitamins, and a small dose of haloperidol, and she was weaned off the morphine infusion over several days. Soon thereafter I visited her and asked her what the problem was. She said that her family was not visiting her.
A “terminal” human immunodeficiency (HIV) patient was hospitalized with delirium and severe pain, and was presumed to be imminently dying. His sister had taken leave from work and wanted to bring him home to die. He was not cachetic, his viral load was not high, and he did not look terminal. He was started on a small dose of haloperidol, switched to intravenous hydromorphone, and within a few days became lucid and went home with his sister.
The last patient was a 71-year-old woman who was a patient of mine with a chronic lumbar postlaminectomy syndrome on methadone 20 mg twice daily. She had been stable on this dose for many years. She was seen every 3 months. Unknown to me, her cardiologist, at another hospital, had admitted her to hospice. She had been admitted and treated for pneumonia, low-output congestive heart failure, and renal failure. At discharge she was placed on liquid morphine per hospice's recommendation for chest pain. The hospice nurse asked me to arrange for a subcutaneous morphine infusion. I presumed my patient was dying of cardiac failure. Before beginning the infusion I made a home visit. When I saw her, it was apparent that her chest pain was left-sided, lateral and posterior. She had rales over that area and pain on inspiration and body movement. She was coughing up green sputum but had no fever. This was pleuritic chest pain secondary to pneumonia. Both she and the family wanted an antibiotic, which her pulmonary physician supplied. Two weeks later she was much better with resolution of her chest pain. She died many months later.
Why tell these stories? Because I wonder how many such well-meaning mistakes are “out there,” and I wonder how and by whom they are handled. As hospices seem to be getting more and more of the health care dollar, how can we be assured that organizations are delivering quality care, or do we believe that “hospice” guarantees quality? Are family and patient satisfaction the ultimate tests of quality? How often is quality care assumed to be delivered just because … First and most important, who is actually in charge of quality care? Is it the executive director, a nurse, an advanced practice registered nurse, a physician assistant, a physician medical director? Does that person feel the heat when tough “things” need to be said about the organization, the clinical team members, or mistakes? When there are particular referring groups or individuals whose care is poor, how is this handled? Do any board members participate in clinical quality assurance or is blind acceptance the mantra of the board? Is the top clinically qualified individual in charge of quality assurance? Is quality assurance equated to risk management? Lastly, are there even universally acceptable tools that truly help to measure quality and not just the common use of a tool? Just because an organization cares does not mean it knows how to deliver quality care or how to measure it.