News News Doctors Lack Training in Hospice Care
Do older cancer patients have a higher pain tolerance? Or are they less able to report pain effectively? Walter Forman, M.D., geriatric oncologist and clinical director of the University of New Mexico Cancer Center, Albuquerque, believes older patients are externally stimulated — that is, they believe that a physician will ask about pain and tell them how to manage the pain. "Older patients tend not to report pain so as not to displease the doctor or distract the physician from the mission of 'curing' the cause of their pain," Forman said. "Older patients tend to give more deference to doctors," added Cheryl Arenella, M.D., medical director of Hospice of Northern Virginia, Falls Church. When asked to describe pain on a scale of 1 to 10, with 10 being worst pain imaginable, an older patient may report a 5, Forman said. But without the outside stimulus of a physician asking about the pain, the same older patient may never mention the pain.
Many cancer patients are missing out on the palliative care provided in hospice because of poor funding, poor patient access, and too few in-patient hospice programs, according to hospice experts. And too few doctors are referring patients to hospice. "We have patients who simply aren't referred because many of our physicians are not taught how to do this," said Michael Levy, M.D., medical director of Palliative Care Services at the Fox Chase Cancer Center, Philadelphia. "Hospice palliative care has to be looked at not as a failure — not as the antithesis of the goals of comprehensive care — but as the completion," he added. Although cure may not be possible, care is available. More than 210,000 patients are enrolled in hospice, according to the National Hospice Organization. Of these.
"Good" Patients Get Attention Patients feel that complaints about pain will influence the quality of their care; that is, "good" patients will receive more time and attention. Forman said surveys have shown physicians are least likely to spend time with patients with unresolved pain. Family members may reinforce the stereotypical attitude toward a "bad patient" by expressing concern that their parent is complaining too much. Forman believes it is important to understand the psychological and physiological differences among cohort groups of older patients — for example,
Vol. 84, No. 15, August 5, 1992
Dr. Walter Forman
ages 65 to 75,75 to 85, and over 85 — and consider these variations when treating older patients. For example, the physiological changes in a patient over 85 may require prescribing lower doses of analgesics because of an increased sensitivity to drugs and side effects. In addition, patients over 85 grew up during Prohibition, Forman said, so this cohort has particular fears of opioids that younger cohorts do not. Medications must be titrated carefully, according to Arenella, because older cancer patients often have multiple medical problems and are on multiple medications. Arenella said it is important to apply general principles of geriatrics when treating an older cancer patient with pain. "You need to be aware of possible hearing or visual deficits," she said, because the older patient may be reluctant to disclose such a deficit. Susan Nayfield, M.D., of the National Cancer Institute's Division of Prevention and Control, said an increased interest in pain control has resulted in new assessment tools, drugs, and methods of delivery, such as the transdermal patch, which can be used for the elderly as well. —Julie A. Sleek
Downloaded from http://jnci.oxfordjournals.org/ at University of Chicago on July 13, 2015
Cancer Pain in the Elderly Needs Special Attention
Dr. Michael Levy
NEWS
1153
News News 84% are cancer patients. The hospice patient is someone with a life expectancy of 6 months or less, for whom curative treatment is no longer effective, said Levy, who spoke about hospice at a recent National Cancer Advisory Board meeting.
Awards, Appointments, Announcements
Ken Miller, M.D., medical director of Montgomery County Hospice, Md., who also spoke at the meeting, agreed that physicians do not receive adequate training in palliative treatment and, therefore, may not be comfortable with it. He said that in 10 years of medical training, he had one lecture on pain control. Before 1990, there were no formal hospice training programs for physicians. Two years ago, the Academy of Hospice Physicians set up a physician training program. Open to practicing physicians of all specialties, the program focuses on aspects of hospice care including ethical and legal issues, symptom control, patient-doctor communication, reimbursement and funding of hospice programs, as well as issues related to death and dying.
Dr. Ken Miller
Earlier this year, the University of Texas M. D. Anderson Cancer Center in collaboration with the Hospice at the Texas Medical Center, Houston, established a 1-year fellowship in hospice medicine. The goal of these programs is to create awareness among physicians about symptom control and patient comfort in terminal illness.
Too Late Late referrals are another area of concern to hospice personnel. "We are getting patients far too late," said Muriel Foos, president of the Hospice Council of Metropolitan Washington, D.C. She believes that early counseling and referral make the hospice concept more acceptable to the patient. In reality, Miller noted, doctors have a hard time telling a patient that his or her cancer is progressing despite treatment. "It is emotionally sometimes easier just to switch to a new protocol or to add another drug to the regimen," he said. Muriel FOGS
1154
— Karen Vaucrosson
Arizona Researcher Honored This year's Jeffrey A. Gottlieb Memorial Award went to Evan M. Hersh, M.D., co-director of the Arizona Cancer Center's Clinical Oncology Research Program and chief of the Section of Hematology and Oncology. The Gottleib Award, furnished by the University of Texas M. D. Anderson Cancer Center in Houston, recognizes outstanding achievement in cancer therapeutic research. Past recipients are Vincent T. DeVita, Jr., M.D., and Steven Rosenberg, M.D., Ph.D.
Pew Scholars Twenty young scientists were named 1992 Pew Scholars in Biomedical Sciences by the Pew Charitable Trusts in Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at University of Chicago on July 13, 2015
Inadequate Training
American Cancer Society Clinical Research Professorships were awarded to H. Rodney Withers, M.D., D.Sc, University of California, Los Angeles, and Alan Solomon, M.D., University of Tennessee Medical Center. The award provides recipients with funding for their entire career and freedom from academic tasks. Each researcher will receive $250,000 for 5 years, with renewal every 5 years. These new awards bring the total number of ACS clinical research professors to five. Withers' research focuses on aspects of radiation biology directly related to radiation therapy. Solomon has been studying the pathophysiologic roles of monoclonal immunoglobulin light chain proteins to improve diagnosis, treatment, and prevention of related diseases, such as B-cell lymphomas.
Do older cancer patients have a higher pain tolerance? Or are they less able to report pain effectively? Walter Forman, M.D., geriatric oncologist and clinical director of the University of New Mexico Cancer Center, Albuquerque, believes older patients are externally stimulated — that is, they believe that a physician will ask about pain and tell them how to manage the pain. "Older patients tend not to report pain so as not to displease the doctor or distract the physician from the mission of 'curing' the cause of their pain," Forman said. "Older patients tend to give more deference to doctors," added Cheryl Arenella, M.D., medical director of Hospice of Northern Virginia, Falls Church. When asked to describe pain on a scale of 1 to 10, with 10 being worst pain imaginable, an older patient may report a 5, Forman said. But without the outside stimulus of a physician asking about the pain, the same older patient may never mention the pain.
Many cancer patients are missing out on the palliative care provided in hospice because of poor funding, poor patient access, and too few in-patient hospice programs, according to hospice experts. And too few doctors are referring patients to hospice. "We have patients who simply aren't referred because many of our physicians are not taught how to do this," said Michael Levy, M.D., medical director of Palliative Care Services at the Fox Chase Cancer Center, Philadelphia. "Hospice palliative care has to be looked at not as a failure — not as the antithesis of the goals of comprehensive care — but as the completion," he added. Although cure may not be possible, care is available. More than 210,000 patients are enrolled in hospice, according to the National Hospice Organization. Of these.
"Good" Patients Get Attention Patients feel that complaints about pain will influence the quality of their care; that is, "good" patients will receive more time and attention. Forman said surveys have shown physicians are least likely to spend time with patients with unresolved pain. Family members may reinforce the stereotypical attitude toward a "bad patient" by expressing concern that their parent is complaining too much. Forman believes it is important to understand the psychological and physiological differences among cohort groups of older patients — for example,
Vol. 84, No. 15, August 5, 1992
Dr. Walter Forman
ages 65 to 75,75 to 85, and over 85 — and consider these variations when treating older patients. For example, the physiological changes in a patient over 85 may require prescribing lower doses of analgesics because of an increased sensitivity to drugs and side effects. In addition, patients over 85 grew up during Prohibition, Forman said, so this cohort has particular fears of opioids that younger cohorts do not. Medications must be titrated carefully, according to Arenella, because older cancer patients often have multiple medical problems and are on multiple medications. Arenella said it is important to apply general principles of geriatrics when treating an older cancer patient with pain. "You need to be aware of possible hearing or visual deficits," she said, because the older patient may be reluctant to disclose such a deficit. Susan Nayfield, M.D., of the National Cancer Institute's Division of Prevention and Control, said an increased interest in pain control has resulted in new assessment tools, drugs, and methods of delivery, such as the transdermal patch, which can be used for the elderly as well. —Julie A. Sleek
Downloaded from http://jnci.oxfordjournals.org/ at University of Chicago on July 13, 2015
Cancer Pain in the Elderly Needs Special Attention
Dr. Michael Levy
NEWS
1153
News News 84% are cancer patients. The hospice patient is someone with a life expectancy of 6 months or less, for whom curative treatment is no longer effective, said Levy, who spoke about hospice at a recent National Cancer Advisory Board meeting.
Awards, Appointments, Announcements
Ken Miller, M.D., medical director of Montgomery County Hospice, Md., who also spoke at the meeting, agreed that physicians do not receive adequate training in palliative treatment and, therefore, may not be comfortable with it. He said that in 10 years of medical training, he had one lecture on pain control. Before 1990, there were no formal hospice training programs for physicians. Two years ago, the Academy of Hospice Physicians set up a physician training program. Open to practicing physicians of all specialties, the program focuses on aspects of hospice care including ethical and legal issues, symptom control, patient-doctor communication, reimbursement and funding of hospice programs, as well as issues related to death and dying.
Dr. Ken Miller
Earlier this year, the University of Texas M. D. Anderson Cancer Center in collaboration with the Hospice at the Texas Medical Center, Houston, established a 1-year fellowship in hospice medicine. The goal of these programs is to create awareness among physicians about symptom control and patient comfort in terminal illness.
Too Late Late referrals are another area of concern to hospice personnel. "We are getting patients far too late," said Muriel Foos, president of the Hospice Council of Metropolitan Washington, D.C. She believes that early counseling and referral make the hospice concept more acceptable to the patient. In reality, Miller noted, doctors have a hard time telling a patient that his or her cancer is progressing despite treatment. "It is emotionally sometimes easier just to switch to a new protocol or to add another drug to the regimen," he said. Muriel FOGS
1154
— Karen Vaucrosson
Arizona Researcher Honored This year's Jeffrey A. Gottlieb Memorial Award went to Evan M. Hersh, M.D., co-director of the Arizona Cancer Center's Clinical Oncology Research Program and chief of the Section of Hematology and Oncology. The Gottleib Award, furnished by the University of Texas M. D. Anderson Cancer Center in Houston, recognizes outstanding achievement in cancer therapeutic research. Past recipients are Vincent T. DeVita, Jr., M.D., and Steven Rosenberg, M.D., Ph.D.
Pew Scholars Twenty young scientists were named 1992 Pew Scholars in Biomedical Sciences by the Pew Charitable Trusts in Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at University of Chicago on July 13, 2015
Inadequate Training
American Cancer Society Clinical Research Professorships were awarded to H. Rodney Withers, M.D., D.Sc, University of California, Los Angeles, and Alan Solomon, M.D., University of Tennessee Medical Center. The award provides recipients with funding for their entire career and freedom from academic tasks. Each researcher will receive $250,000 for 5 years, with renewal every 5 years. These new awards bring the total number of ACS clinical research professors to five. Withers' research focuses on aspects of radiation biology directly related to radiation therapy. Solomon has been studying the pathophysiologic roles of monoclonal immunoglobulin light chain proteins to improve diagnosis, treatment, and prevention of related diseases, such as B-cell lymphomas.
