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Tuesday, June 28, 2016

Heads-Up, Students: No Shot, No College

As college-bound students pack their bags to move into the dorm, the physicians of the Texas Medical Association (TMA) want to remind them about an important and required vaccination. Texas law requires almost all new and transfer college students under age 22 to be vaccinated against meningococcal disease at least 10 days before classes begin, or to show proof of vaccination within the previous five years.

“Meningococcal infection spreads among people who live in close quarters, like a college dorm or a military barracks, so college students need this vaccine,” said Carol J. Baker, MD, of Houston, a pediatric infectious disease specialist and a member of TMA’s Be Wise — ImmunizeSM Physician Advisory Panel.

Meningococcal disease includes infections of the brain’s lining and spinal cord (meningitis) and the bloodstream (bacteremia or septicemia) caused by the bacteria Neisseria meningitidis, or meningococcus. A healthy, nonsusceptible person can spread the bacteria to a healthy, susceptible person through coughing, sneezing, sharing drinks or eating utensils, or kissing.

Meningococcal disease strikes quickly with fever, headache, severe muscle aches — and later, stiff neck. The illness can seem like flu, but progresses with vomiting, weakness, mental confusion, shock, and sometimes a purple rash on the extremities. Emergency medical attention is important.

“These infections can become deadly in just a few hours,” said Dr. Baker. “With antibiotic treatment, some sufferers can survive, but up to 15 percent have lasting consequences.”

About one in 10 people who get meningococcal disease will die ― often within hours of the onset of symptoms and the start of treatment. Survivors can suffer severe, lifelong complications, such as hearing loss; amputations of fingers, toes or even arms or legs; and skin scarring.

The good news is that vaccination can prevent meningococcal disease. As many as four out of five adolescents and young adults who contract the infection could have avoided it had they been vaccinated. The meningococcal vaccine protects against the most common strains seen in the United States, namely groups A, C, W, and Y.

If an incoming college student’s vaccinations are up to date, he or she likely had a meningococcal vaccination at age 11 and 12. Protection from the vaccine lasts for only several years, so a second vaccination is needed at age 16-18 to protect young adults during the years when they are at highest risk for meningococcal disease.

“This ‘shot of prevention’ is an easy way to keep students healthy as they head off to their first phase of adulthood,” said Dr. Baker.

Students should check with their doctor to see if they are up to date with all recommended vaccines. Free or low-cost vaccinations may be available for teens and young adults who don’t have health insurance.

TMA has published a fact sheet about the importance of meningococcal vaccination, in English and Spanish.

It’s best to check and get vaccinated now, doctors say, well before packing those first items for college.

Tuesday, June 14, 2016

Men: Pay Attention to Your Health

Correctly or not, most men are known for not staying on top of their health: A few beers here, brisket or burger there … or putting off that doctor checkup. During Men’s Health Week (June 13-19), the physicians of the Texas Medical Association (TMA) want to remind men to make their health a priority — for themselves and their families. After all, doctors say, keeping healthy has its rewards: avoiding chronic disease and allowing more quality time with friends and family.

“Some simple things can mean huge improvements in our health,” said Lenore DePagter, DO, a San Marcos internist. “We physicians prefer to help our patients improve their health, rather than having to treat them when illness or disease strikes.”

Men’s Health Week aims to raise awareness of preventable health problems and encourage men and boys to seek regular medical advice and early treatment for disease and injury.

A simple path to good health includes eating right, staying active, quitting smoking, and staying up to date on vaccinations, say Texas physicians in TMA’s Healthy Vision 2020.

Obesity
There’s work to be done: Nearly one-third (31.9 percent) of Texas adults are obese, making it the 11th most obese state in the nation, according to The State of Obesity: Better Policies for a Healthier America. And obesity rates are highest in adults aged 40-59 years, according to the National Health Interview Survey. Obesity and being overweight can contribute to a host of health problems, including diabetes, heart disease, cancer, and stroke.

Adults are urged to get 150 minutes of moderate exercise weekly, plus some muscle-strengthening activities.

If someone hasn’t been active, walking is a great way to start improving health, said Dr. DePagter. Then he or she can work up to longer, and possibly more intense, activity. But she added it’s wise to talk with the doctor before beginning any physical activity.

Tobacco
Quitting tobacco also can have an immediate positive impact on a person’s health. No matter the person’s age and what form of tobacco used — cigarettes, cigars, smokeless tobacco, or e-cigarettes — quitting has benefits. Texas has a 10 percent higher-than-average rate of death attributable to smoking, or 273 deaths per 100,000.

Vaccinations
Staying up to date with vaccinations is another way to prevent illness and possible death. Even if a man had all recommended shots as a child, Dr. DePagter says men need several as an adult. For example:

  • A yearly flu shot is recommended for everyone six months of age and older.
  • Depending on age, a man might need a tetanus booster to protect from cuts and injuries.
  • Pertussis (or whooping cough) boosters protect both a father and mother and their baby.
  • A Zoster vaccination protects anyone against shingles.

TMA has an adult vaccination chart and an adult vaccination fact sheet to help patients see what shots they need based on their age. Men should check with their doctor to make sure they are up-to-date on all their shots.

“On Father’s Day, we celebrate the strong men who have made a difference in our families and in our lives,” said Dr. DePagter. “It’s up to every man to take control of his health so he can be part of this day for years to come.”

Monday, June 13, 2016

Walking the Walk: Time Is Short

By Ana Leech, MD
Houston Palliative Care and Hospice Physician
Medical Director Memorial Hermann Hospice IPUMedical Director of Palliative Medicine Memorial Hermann Southwest

Editor’s Note: Physician Ana Leech, MD, shares her family’s experience caring for her father, who has a terminal illness. As a hospice and palliative medicine physician, Dr. Leech is able to tell her story from both a personal and medical perspective. This is the third part in a series she wrote as a collection of updates over time. Read parts one and two.

Dad slept better his first night on hospice care. Mom had medications to give him and she felt safer, knowing that help is just a phone call away now.

His health declined enough to sign up for hospice before his 80th birthday. I was hoping he would have his birthday first, but that was not to be. Regardless, he had a great time and we were glad he was doing well enough to be aware of the party.

Although hospice patients are not home bound, my parents don’t really leave the house much these days. Dad gets confused and doesn’t remember where he is, plus he doesn’t want to be a passenger in the car. He wants to drive. And he really doesn’t need to be behind the wheel anymore ― for anyone’s sake.

-----

It gets harder every day. He is disoriented and sometimes forgets who Mom is. He is also obsessed with driving (which he has been doing since he was 12) and it creates a lot of problems for Mom. He tries to sneak the keys, and then gets upset and throws tantrums when she won't let him drive. He is also fixated on cars ― although that is not new. He looks out the window to make sure his car is still there. Last week he insisted he owns three cars and that two are missing from the driveway. He thinks maybe Mom is hiding them from him.

He sleeps so much now. He basically wakes up to eat and goes back to sleep. This is better for Mom because when he is asleep she can rest.

I am not sure how much longer he has, but the person who raised me is gone. Just the shell of his body remains. It hurts so much. Last summer my father was a robust man in his 70s, fully independent and gregarious. Today he is unable to walk on his own and only says a few occasional words which usually don't make sense. He is gone, but his body remains here to suffer and put my mom through the most difficult time of her life.

-----

He has declined markedly in the past couple of days. He has what we call agitated delirium every night. Not sure if it is pain (physical or emotional) or if he is afraid to die. I know he has unfinished business. A book he wanted to publish, another business to start…I just wish we could convey to him that he has done his life's work so that he could let go.

Mom needs more help now; it is so difficult to take care of him like this. I think she should let the hospice people care for him in the inpatient unit, but she wants to take care of him at home. She feels it is her responsibility and that taking him there would be a failure on her part. She has done such a good job for the past couple of months, but he needs a higher level of care. We will work on crisis care, but if his symptoms don't improve, I really hope she will agree to the transfer. They both need to rest.

I can't stop crying. Not because he is dying, but because he is not. He is uncomfortable and miserable and can't die because he is suffering so much. He needs to be sedated. Maybe then he'll relax enough to let his soul fly.

-----

He is actively dying now. It is crazy to know that he will only be here a few more hours. He has been here all my life and now he'll be gone. I know enough to help Mom go through this and also enough to feel a weird pain that no one can feel. Being on both sides of the equation is a rather eerie feeling. I know what the nurse is thinking — but I am also his child feeling what family feels. I so wish for God to be gentle with him and take him soon. May these final hours be just a few.

-----

He showed some signs of dying, but certainly not most. He was comfortable and his symptoms were well controlled by the crisis care nurses that came to his home to be there in his last hours. Then with minimal warning, he just stopped breathing. He let his soul go be with his mother and to wait for us until it is our turn.

Wednesday, June 8, 2016

TMA Offers Remedies to Ease Surprise Billing

Texas patients sometimes feel the pain from unexpected out-of-pocket costs not covered by their health insurance, known as “surprise billing” or “balance billing.” The Texas Medical Association (TMA) is taking aim at the problem, which occurs when a health insurance company pays less than what a doctor charges, leaving the patient to pay the balance of the bill.

TMA assembled a group of physician leaders, the Balance Billing Task Force, to study the issue, reports Texas Medicine magazine. Among the causes TMA research found for why patients are increasingly weighed down with unexpected out-of-pocket costs: insurance companies selling plans with limited networks and high deductibles, plus notoriously inaccurate network directories.

Often the “surprise” in this billing is due partly to the health insurance companies’ failure to help their customers understand how their insurance coverage works. Several things are happening due to this lack of understanding:

  1. Patients might incorrectly assume the care they are receiving is covered by their policy;
  2. The insured patient might not yet have met his or her deductible, meaning he or she must pay more out of pocket before insurance benefits kick in; and
  3. The physician or health care provider treating the patient might not be in the network list for that patient’s health plan. In that situation, when patients receive care from a doctor not listed in their insurance plan’s network, the health insurance company can refuse to pay for some or all of that out-of-network medical care. As a result, the out-of-network physician may charge the insured patient for the remaining balance of the bill.

Some states are seeking to stop surprise bills by limiting physicians’ ability to bill patients for the balance owed in those situations, but TMA physician leaders say lawmakers must hold health insurers accountable for the larger problems of inadequate networks, policy limits, and other business practices.

“Nobody wants surprise bills. But the real problem is not balance billing. The real problem is narrow networks [health insurance networks with a limited choice of physicians and health care providers],” said Denton obstetrician-gynecologist Joseph Valenti, MD, Balance Billing Task Force member and former chair of TMA’s Council on Socioeconomics. “Patients are in the middle of this because it’s not made clear to them what they are purchasing.”

Health plans want to cut costs and increase profits. One way to accomplish this is to pay less for care, and one way to accomplish that is to have fewer doctors in the plan’s provider network, forcing more patients to receive out-of-network care. Then the patient is responsible for paying more of his or her medical bills, while the insurer pays less.

“The narrower [insurers] make these networks, the more they shift costs onto patients and doctors, and if regulators don't look at this, we are all in big trouble,” Dr. Valenti said.

It’s not for lack of trying on physicians’ part, TMA leaders say. For 61 percent of doctors who tried to join a plan’s network, the insurer essentially said no. (According to TMA and Texas physician surveys, 32 percent of those physicians received an unacceptable offer from the insurer, while 29 percent received no response at all.)

"We try hard to be in network,” said Keith A. Bourgeois, MD, chair of TMA’s Balance Billing Task Force. “The big dilemma is that sometimes being out of network is not a choice of the practice.” He said in those cases, the insurance company makes that choice; doctors receive “low-ball, take-it-or-leave-it offers” from health insurers, which are difficult for a business to accept (and doctors’ offices are businesses with overhead and employees just like any other business).

“I just renegotiated my lease, and the building expects a 3-percent rise every year,” said Dr. Bourgeois, a Houston ophthalmologist. “Many of the [insurance] contracts I hold are the same as they were 10 years ago.”

According to TMA research, only two insurers offer broad preferred provider organization (PPO) networks ¾ containing ample physicians for patients to see ¾ in Texas’ 2016 Affordable Care Act insurance marketplace, and both sell only regional coverage. In the 2015 health insurance marketplace, four health plans offered hundreds of PPO plans across the state.

TMA says it will support legislation to preserve physicians’ rights to bill for care they provide, while at the same time arming patients with more information to lessen the likelihood of receiving a surprise bill.

“Lawmakers want physicians to be a part of the solution. And we want the same things our patients want, which is transparency, not just from physicians but from all health plans and all health care providers, because our patients don't deserve to get a surprise bill,” said Beaumont anesthesiologist Ray Callas, MD, task force member and chair of TMA’s Council on Legislation.

Dr. Callas recently presented TMA’s new legislative recommendations to protect and inform patients to the Senate Committee on Business and Commerce, and the House Committee on Insurance. TMA recommends:

  • Mandatory increase in state agency oversight of the adequacy of insurer networks, especially for insurers often brought to mediation by patients.
  • Expanding the current mediation process to include all out-of-network physicians, other health care professionals, and vendors providing services at a facility. (The current mediation process pertains only to some out-of-network, hospital-based physicians. The current mediation threshold of a $500 balance after copayments, deductibles and coinsurance should be maintained.)
  • Expansion of the current mediation process to apply to any out-of-network hospital, outpatient hospital, ambulatory surgical center, free-standing emergency medical facility or department, and ground ambulance services.
  • Requiring that, prior to any preauthorized elective services, the insurer inform the patient about the network status of the facility-based physicians and others who may bill for services.
  • Use of a standard form by physicians and providers to tell patients which physicians and providers might be involved in their care and how to contact them. Physicians and providers also should advise patients that it’s possible that another doctor or provider might treat the patient when unforeseen scheduling or staffing changes at the facility occur.
  • Requiring insurers selling PPOs to include “a clear and conspicuous notice regarding the implications of using or receiving services from an out-of-network physician … and the potential for balance billing” on their websites, policy documents, and directories.
  • Requiring insurance brokers and agents to educate consumers about the inherent limitations of the plans they buy, especially their out-of-pocket responsibilities for care provided both in and out of network.

TMA has also unveiled “Why Did I Get That Medical Bill?” to help explain to the public the root causes of unexpected medical bills.

 “[Having narrow networks with too few doctors] is like buying a warranty on a car and finding out there’s only one shop in the entire [town] you can take your car to,” said Dr. Valenti.

Tuesday, May 31, 2016

Hepatitis C Associated With Head and Neck Cancer

Hepatitis C virus (HCV), a virus linked to liver cancer and non-Hodgkin’s lymphoma, also has a strong association with head and neck cancers, according to a new study conducted by The University of Texas MD Anderson Cancer Center and published in the Journal of the National Cancer Institute. The study suggests that screening for HCV in patients with head and neck cancer is very important because HCV seems to be associated with nonoropharyngeal head and neck cancers and HPV (human papillomavirus)-positive oropharyngeal cancers. (Oropharyngeal refers to the middle part of the throat.)

Harrys A. Torres, MD, lead author of the study and associate professor of infectious disease, infection control, and employee health at MD Anderson, said the impetus behind the study came when he noticed several HCV patients in his cancer clinic had head and neck cancer.

“What I was expecting to see in that clinic was a significant number of patients with hepatocellular carcinoma (HCC, a type of liver cancer), and probably non-Hodgkin’s lymphoma, because these are the top two cancers associated with HCV. However, I started seeing several patients come in with head and neck cancer, and I didn’t know why.”

Dr. Torres looked at patient data from 34,545 MD Anderson cancer patients, 409 of whom had head and neck cancers. The data revealed between 14 to 20 percent of head and neck cancer patients (depending on the type of head and neck cancer) had tested positive for HCV antibodies.

“Around 1.5 percent of the United States population is infected with hepatitis C, so these findings are significantly higher,” said Dr. Torres. In fact, the study revealed patients with HCV infection are two to five times more likely to have a head and neck cancer than other tobacco-related cancers.

Since HCV is a curable infection when treated with the latest drugs on the market, treating for HCV could be an opportunity to prevent or improve the outcome of HCV-associated cancers.

“If we identify hepatitis C early and we treat these patients, there is a very good chance we are going to reduce the number of all these cancers associated with the virus and reduce the potential for complications like hepatic toxicity (chemical liver damage) during the treatment of their existing cancer,” said Dr. Torres. “That has been proven in HCC. We know that when we treat hepatitis C the incidence of HCC will decrease. It is the same for non-Hodgkin’s lymphoma. It remains to be explored whether curing the infection reduces the risk of head and neck cancers, as we do not know if this epidemiological association is causal, i.e. whether the virus directly causes head and neck cancers.”

Dr. Torres said the challenge now is getting at-risk Americans into clinics to be screened for HCV, a disease which for the most part has no symptoms.

“That is one of the major problems with HCV — patients are not aware they have it. When patients do ultimately have symptoms, most of the time it’s too late for curable treatment. They have developed advanced cirrhosis (liver damage) and treatment is not even possible because it is so advanced. That is why screening is so important for early detection of this infection.”

The Centers for Disease Control and Prevention recommends all baby boomers (those born between 1945 through 1965) be tested once for HCV even if they do not have any other risk factors, because 75 percent of all HCV infections occur in baby boomers. Risk factors for HCV infection include injection drug use, having received a blood or organ donation before 1992, HIV infection, and certain medical conditions.

Promoting this testing recommendation is also a focus of Texas HepCA, a team of oncologists and hepatologists (cancer and liver specialists) working with the Texas Medical Association’s (TMA’s) Committee on Cancer and TMA Foundation (TMA’s philanthropic arm) to increase awareness of and education about HCC. HCV is a known cause of HCC due to the damage it inflicts on the liver in the form of cirrhosis.

Dr. Torres cautioned that this study does not prove HCV directly causes head and neck cancers, but it is the first study to reveal a strong association between the two.

“Our study is just the first step to address knowledge gaps related to the oncologic (cancer) impact of HCV. The next step is to do further research,” he said.

He also stressed that tobacco, excessive alcohol use, and HPV infection remain the most important risk factors for head and neck cancers. “All people — with or without HCV infection — should consider lifestyle changes to reduce the risk of these cancers.”

Thursday, May 26, 2016

The ABCs of Hepatitis: What It Is; How to Prevent It

By Janice Stachowiak, MD
Lubbock Internist
Member, TMA Be Wise ― ImmunizeSM Physician Advisory Panel

May is Hepatitis Awareness Month. While May is almost over, you can benefit anytime by knowing how to prevent hepatitis, inflammation of the liver. Liver inflammation can have several causes, including alcohol, medications, and viral infections. I will focus on viral causes of hepatitis, especially those that can be prevented by vaccines. In the United States, the most frequent types of viral hepatitis are hepatitis A, hepatitis B, and hepatitis C.

Hepatitis A:


Hepatitis A usually is caused by consuming contaminated food or water or through person-to-person contact, such as when an infected person does not wash his or her hands properly after using the bathroom and touches other objects. Some people with hepatitis A have no signs of illness, some have a mild illness, and others are severely ill. Symptoms of Hepatitis A can include fever, fatigue, loss of appetite, nausea, vomiting, stomach pain, dark urine, light or clay-colored stools, and jaundice (yellowing of the skin and eyes). These symptoms can last a few weeks to several months.

The older a person and the more medical problems they have — especially prior liver disease — the more severe symptoms are likely to be. In rare cases, hepatitis A can be life-threatening. Once someone recovers from hepatitis A, he or she has antibodies to protect from further episodes of hepatitis A for life. Hepatitis A also does not cause a long-term infection that can lead to cirrhosis (scarring of the liver).

The best way to prevent hepatitis A is through vaccination. Vaccination is recommended for children 1 year of age or older, travelers to certain countries, and other adults at high risk for severe illness should they have contracted hepatitis A, such as people with chronic liver disease. The hepatitis A vaccine is given as two shots, six months apart. Adults 18 years of age or older can get a combination vaccine that protects against both hepatitis A and B; this is given as three shots over six months. Protection begins approximately two to four weeks after getting the hepatitis A vaccine. If you are traveling outside of the United States this summer, you can check if the hepatitis A vaccine is recommended for your destination. Getting vaccinated two or more weeks before departure is best but even getting the shot a few days before you leave will offer some protection.


Hepatitis B:


Hepatitis B can be transmitted several ways: Through sexual contact; the sharing of needles, syringes, or other drug-injection equipment; the exposure to blood from needle sticks or other sharp instruments; or from mother to baby at birth. People living with diabetes or on hemodialysis (a procedure to treat kidney failure that filters waste and removes extra fluid from the blood) can be at increased risk. In some Asian countries hepatitis B is so prevalent, mother-to-child transmission is common. For some people, hepatitis B is a short-term illness. For others, it can be a long-term, chronic infection. The younger a person is when he or she contracts hepatitis B, the greater the risk of long-lasting infection. Chronic hepatitis B (a long-term condition) can lead to cirrhosis or liver cancer.

Most adults will develop symptoms with an acute hepatitis B infection (a shorter-term severe case), while most children will not. Symptoms of acute hepatitis B infection are similar to hepatitis A: fever, nausea, vomiting, dark urine, and jaundice. An acute infection can last a few weeks to several months. People who develop chronic hepatitis B can remain symptom-free for as long as 20 to 30 years after the initial infection. Acute and chronic hepatitis B can be diagnosed with blood tests. Treatment is available for people with complications from chronic hepatitis B, but it doesn’t work in all cases.

Again, the best way to prevent hepatitis B is through vaccination. All children should get their first hepatitis B shot at birth and complete the series by 6-18 months of age. All children and adolescents younger than 19 years of age who were never vaccinated should get the shots. Any adult at increased risk or who wants to be protected against hepatitis B can be vaccinated. I received my hepatitis B shots while I was in medical school.


Hepatitis C:


Hepatitis C usually is spread when blood from an infected person enters the body of someone else who is not infected. The most common form of transmission is sharing needles or equipment to inject drugs. Less commonly, a person can get hepatitis C through sexual contact.

Approximately 70 to 80 percent of people with acute hepatitis C do not have symptoms. Many people with acute hepatitis C will develop chronic hepatitis C that can lead to cirrhosis and liver cancer.

Testing for Hepatitis C is recommended for:

  • Anyone born between 1945 and 1965;
  • Anyone who received a blood transfusion or organ donation before 1992;
  • Anyone treated for a blood clotting disorder before 1987;
  • Anyone who has injected drugs — even only once; and
  • Anyone infected with HIV.  

The treatment options for people with chronic hepatitis C have greatly improved during the past several years. However, no vaccine currently is available for hepatitis C. The best prevention is to avoid the behaviors that can spread the virus, such as sharing needles.

Dr. Stachowiak, an internist from Lubbock, teaches at Texas Tech University Health Sciences Center in Lubbock. She is a member of TMA’s Be Wise – ImmunizeSM Physician Advisory Panel and is a member of the South Plains Immunization Network.

Wednesday, May 18, 2016

Walking the Walk: Making Choices

By Ana Leech, MD
Houston Palliative Care and Hospice Physician
Medical Director Memorial Hermann Hospice IPUMedical Director of Palliative Medicine Memorial Hermann Southwest

Editor’s Note: Physician Ana Leech, MD, shares her family’s experience caring for her father, who has a terminal illness. As a hospice and palliative medicine physician, Dr. Leech is able to tell her story from both a personal and medical perspective. This is the second part in a series. Read part one here.


My mom doesn’t know what hospice is. No one does unless he or she needs the services. In reality, even many doctors who refer patients to hospice don’t really understand it. So it was no surprise that Mom rejected it when I first introduced the idea to her. Her first comment was “No. I want to take care of him at home.”  

But hospice wants her to take care of him at home. The whole system assumes that is what will happen. Hospice would help.

Dad is apparently more symptomatic than he leads on. Mom reports he is experiencing nausea, depression, fatigue, and insomnia. She manages with the medications he already has, but the situation is not optimal. I really can’t be objective enough to help her, and I have a personal rule to never care for a loved one, particularly now. The hospice team would be able to manage all those symptoms so he feels better — if only my parents would agree to it.  

Palliative and hospice care are relatively newly recognized in the world of medicine. The general population and much of the medical community are misinformed about the services and care we provide.  

Palliative care is a medical specialty that concentrates on symptoms and quality of life. I like to say I am a “symptomatologist” and quality-of-life expert. The palliative care team is composed of doctors, nurses, chaplains, and social workers. They care for patients with serious illness, providing symptom relief. The team addresses physical as well as spiritual and emotional concerns. Patients can request palliative care when they have a serious illness and they wish to continue treatment plans. Patients who have a palliative team helping them with their symptoms have been shown to be more satisfied with their care and sometimes live longer, even though they tend to stop active treatments sooner. Palliative care is provided alongside other traditional specialties, and insurance companies pay for the services just like they do for any other medical care.
Hospice is not a location, but a service that is specific for patients in the last six months of life. Most patients on hospice are at home (or a nursing home if that is where they routinely live), and their families care for them. The hospice team, also made up of doctors, nurses, chaplains, and social workers, visits the patient on a regular basis to provide physical and emotional support. The team provides all the equipment, medications, and supplies the patient needs. Patients on hospice are expected to decline and die within a few months, so trips to the hospital are not considered beneficial. Instead, the team comes to the patient when there is a problem.
Hospice has four levels of care:
  1. Routine: The patient is at home and his or her family provides the care or the patient is in a nursing home and the family pays for the room and board charges. All medications, equipment, and supplies are provided. Nurses visit routinely and as needed to provide care.  
  1. Respite: The patient is comfortable, but his or her family needs a break to go on vacation, get some sleep, etc.  In this situation, the hospice company provides 24-hour care in a hospice facility for up to five days a month.  
  1. Crisis Care: The patient is not doing well and symptoms are not managed, but the patient and family do not want to leave home. The hospice will place a nurse on site 24 hours a day for one to two days until symptoms improve. The nurse works even more closely with the team doctor during this time.  
  1. Inpatient: The patient is not doing well, either very uncomfortable, in pain, short of breath, or with any other symptom that is not managed well at home. The patient can go to the hospice facility to get a higher level of care with 24-hour nursing care and daily physician visits. This is a short-term stay until symptoms are controlled.  
The levels of care are fluid, and patients transfer from one to the other without difficulty. There is an on-call nurse available 24/7. Insurance usually pays for hospice — including medications needed for comfort — at 100 percent (at least Medicare does).

It has been a few weeks since this all started. Dad is physically okay, but has declined mentally so much. His symptoms resemble Alzheimer’s, and I can’t imagine how difficult it must be for families of dementia patients. He is confused at times, paranoid, and forgetful. He ruminates on opportunities lost, and can’t remember all the good things he accomplished. It is so painful to watch him (and Mom) go through this.

Mom called this morning. It is getting harder to care for him. His thought processes make it very difficult, and he insists on driving, which is a terrible idea. On the phone, Mom was crying, something I have seen her do just a few times in my life. It hurts so much to live through this. I love Dad dearly and already miss him, but watching my parents suffer is worse than death. In a weird way, I feel that death would be comforting now.  

The hospice team met with Mom later that afternoon. Because I hold medical power of attorney, I took care of the paperwork; in his current state, Dad is so paranoid he thinks we are trying have him committed, which couldn’t be further from the truth.

I am glad it is done. It hurts, but I am glad Mom is set up with help now. A doctor with experience caring for dying patients is in charge now. A whole team to support her through this, and beyond, is holding her up. I can be a daughter now and let the hospice team do the medical management, while I concentrate on the emotional journey.

Dr. Leech is a Houston palliative care and hospice physician. She is medical director at Memorial Hermann Hospice IPU and medical director of palliative medicine at Memorial Hermann Southwest.
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