Approaching patients and family members who hope for a miracle.

A clinical problem may arise when caring for patients or their surrogates who prefer continued aggressive care based on the belief that a miracle will occur, despite a clinician's belief that further medical treatment is unlikely to have any meaningful benefit. An evidence-based approach is provided for the clinician by breaking this complex clinical problem into a series of more focused clinical questions and subsequently answering them through a critical appraisal of the existing medical literature. Belief in miracles is found to be common in the United States and is an important determinant of how decisions are made for those with advanced illness.

Evaluating a palliative care intervention for veterans: challenges and lessons learned in a longitudinal study of patients with serious illness.

Context: Longitudinal studies examining care for seriously ill patients are needed to understand patients' experience of illness, evaluate interventions, and improve quality of care. Unfortunately, such studies face substantial methodological challenges.

Objectives: This article describes such challenges and the strategies used to overcome them in a successfully implemented palliative care intervention trial for veterans.

The intersection of need and opportunity: assessing and capitalizing on opportunities to expand hospital-based palliative care services.

Background: To develop and grow most effectively, palliative care programs must consider how best to align their mission with that of their institution. To do so, programs must identify their institutional mission and needs, what palliative care can do to address those needs given available resources, and how the palliative care team can measure and document its value. Such an approach encourages the palliative care team to think strategically and to see themselves and their service as a solution to issues and concerns within the institution.

Provider communication and patient understanding of life-limiting illness and their relationship to patient communication of treatment preferences.

Medical decision making in the context of serious illness ideally involves a patient who understands his or her condition and prognosis and can effectively formulate and communicate his or her care preferences. To understand the relationships among these care processes, we analyzed baseline interview data from veterans enrolled in a randomized controlled trial of a palliative care intervention. Participants were 400 inpatient veterans admitted with a physician-estimated risk of one-year mortality more than 25%; 260 (65%) had cancer as the primary diagnosis.

Pain and palliative medicine.

Severe pain is highly prevalent, with rates of 40% to 70% in patients with advanced cancer, liver disease, heart failure, human immunodeficiency virus, and renal failure. Wide variations in pain assessment and reporting methods and the measurement of multiple symptoms should be addressed in future studies. Regarding psychological approaches, determining whether hypnotherapy or other individual psychotherapeutic interventions reduce pain and/or psychological distress in a palliative care population is difficult.

The VA Ostomy Health-Related Quality of Life Study: objectives, methods, and patient sample.

Objective: To present the design and methods of a multisite study of health-related quality of life (HR-QOL) in veterans living with ostomies.

Research Design And Methods: Veterans from Tucson, Indianapolis, and Los Angeles VA Medical Centers were surveyed using the validated City of Hope ostomy-specific tool (mCOH-QOL-Ostomy) and the SF-36V. Cases (ostomates) had a major gastrointestinal procedure that required an intestinal stoma, while controls had similar procedures for which an ostomy was not required.

Negotiating end-of-life decision making: a comparison of Japanese and U.S. residents' approaches.

Purpose: To compare Japanese and U.S. resident physicians' attitudes, clinical experiences, and emotional responses regarding making disclosures to patients facing incurable illnesses.

Accommodating ethnic diversity: a study of California hospice programs.

Background: Studies have confirmed ethnic disparities in the use of hospice services and identified barriers that minorities face in accessing care.

Objectives: We sought to determine whether hospices provide services that might affect minority participation.

Research Design: We surveyed California hospices to determine whether programs use diverse health care providers and volunteers, offer translation, diverse spiritual care, or outreach materials and whether they plan to expand such services.

End-of-life education using the dramatic arts: the Wit educational initiative.

Caring for dying persons requires skill in interpersonal aspects of care, which may be difficult to teach using conventional educational methods. The Pulitzer Prize-winning play Wit relates the personal story of a patient dying from metastatic ovarian cancer and describes the protagonist's experience with medical care from diagnosis to death. Members of the Department of Medicine at the VA Greater Los Angeles Health care System and the David Geffen School of Medicine, UCLA developed a program that utilized Wit to educate medical students, residents, and staff providers in the humanistic elements of end-of-life care.

Hospice admission practices: where does hospice fit in the continuum of care?

Objectives: To evaluate selected hospice admission practices that could represent barriers to hospice use and the association between these admission practices and organizational characteristics.

Design: From December 1999 to March 2000, hospices were surveyed about selected admission practices, and their responses were linked to the 1999 California Office of Statewide Health Planning and Development's Home and Hospice Care Survey that describes organizational characteristics of California hospices.

Setting: California statewide.

Charity for the dying: who receives unreimbursed hospice care?

Objectives: Many deaths occur among persons without insurance coverage for hospice care. We examined the patient and agency characteristics associated with receiving unreimbursed hospice care in a national survey.

Results: We examined the receipt of unreimbursed care using the 1998 National Home and Hospice Care Survey (NHHCS) discharge dataset.

Cash and compassion: profit status and the delivery of hospice services.

Objectives: To evaluate the relationship of hospice profit status to patient selection and service delivery.

Design: We analyzed responses to the 1997 California Office of Statewide Health Planning and Development (OSHPD) annual home care and hospice survey. Outcomes included the percentages of patients with noncancer diagnoses, referred from long-term care, and with government payers; average length of stay (LOS); the intensity and skill mix of nursing services; and potential availability of chemotherapy and radiotherapy.