JOURNAL OF PALLIATIVE MEDICINE Volume 18, Number 9, 2015 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2015.0026
Evaluating the Need for Palliative Care Services at a General Hospital in Israel Yael Bar-Ze’ev, MD, MPH,1 Yoram Singer, MD,2 and Pesach Shvartzman, MD1,2
Abstract
Background: Most hospitals in Israel do not provide palliative care beds and only few general hospitals have palliative consultation services. To date there are no data on the rate of hospitalizations and the need for palliative care in general hospitals in Israel. Objective: The objective was to characterize patients in need of palliative treatment during hospitalization in a general hospital in Israel. Methods: A retrospective review was performed of a random sample of files of patients admitted to the Internal Medicine Department at the Soroka University Medical Center (SUMC) between May 2007 and April 2008. Patients were defined as in need of palliative care if they had a CARING score ‡13. The data were collected using a structured questionnaire that included sociodemographic data and data on comorbid conditions, main complaints, primary diagnosis, duration of hospitalization, and hospitalization outcome. Results: We reviewed 2795 hospitalizations. Of these, 14.9% were defined as in need of palliative care. Fourteen percent of the patients died during hospitalization and 47% died over the six-month follow-up period. The most common primary diagnosis was malignancy (61%), followed by end-stage pulmonary disease (19%) and Alzheimer’s and other causes of dementia (9%). In only 12 hospitalizations (3.5%) was palliative care arranged for patients at discharge. Conclusions: A high percentage of patients hospitalized in internal medicine divisions could benefit from palliative care. The data presented here could aid hospitals in the integration of palliative care services.
Introduction
T
here is general agreement that palliative treatment is needed for cancer patients, and over time the need for palliative treatment for patients at the end stage of other illnesses1–9 has been recognized increasingly. In Israel, 41,600 people die each year according to data from 2013.10 Only about 10% of patients who required palliative care services actually had access to it.11–12 Most hospitals in Israel do not have any palliative care service. A few general hospitals have palliative consultation services, and there are only two general hospitals with beds specifically dedicated to palliative care.11 The Israel Ministry of Health has made clear recommendations for access to palliative care services.13 One of the recommendations was to provide palliative care services wherever the patient prefers to stay, including general hospitals. To date there are no data on the rate of hospitalization of patients who require palliative care in general hospitals in
Israel. In the present study we collected preliminary data on the extent of the problem and its characteristics. This will provide support information to aid in the planning and evaluation of palliative care services in Israel and could also serve as an aid to other countries facing similar challenges. Methods
The study was conducted at the Soroka University Medical Center (SUMC), the only general hospital in the southern region of Israel, serving a population of 900,000. The study included a retrospective review of a random sample of admissions to seven internal medicine wards, one neurology ward, one oncology ward, and one hemato-oncology ward between May 1, 2007 and April 30, 2008. Fourteen months of hospitalizations were reviewed (10 months in internal medicine departments, 2 in neurology, 2 in oncology and 1 in hemato-oncology). The CARING criteria, a screening tool aimed at identifing patients who may benefit from palliative care,14 were used.
1 Sial Family Medicine and Primary Care Research Center, Division of Community Health, 2Pain and Palliative Care Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Accepted May 19, 2015.
790
HOSPITAL PALLIATIVE CARE
These criteria, which use the National Hospice and Palliative Care Organization (NHPCO) guidelines,15 include several items: C-primary diagnosis of Cancer (10 points) A- ‡ 2 Admissions to the hospital for a chronic illness within the last year (3 points) R-Resident in a nursing home (3 points) I-Intensive care unit admission with multiorgan failure (10 points) N-Noncancer hospice (meeting ‡2 of the NHPCO (12 points) G-Guidelines The final score incorperates a different weight for each item, also taking into account the age of the patient (75, 3 points). Each hospital record was reviewed using a structured questionnaire that included the CARING criteria. Patients with a CARING score ‡13 were defined as in need of palliative care, and further data were collected, including sociodemographic data, comorbidity, main complaints, primary diagnosis, duration of hospitalization, and hospitalization outcome. For comparison we extracted data for all patients hospitalized during the study period in the internal medicine division from the computerized files of the SUMC (linked to the Population Reference Bureau, Ministry of Interior, Israel). The available data included age, gender, mean duration of hospitalization, and date of death (if relevant). Results
We randomly reviewed 2795 hospitalizations from 25,911 admissions of 16,981 patients. The CARING criteria were fulfilled by 417 (14.9%) of the hospitalizations (347 patients, as we included repeated admissions during the study period). In internal medicine wards, 14.8% of hospitalizations fulfilled the criteria, compared to nearly 50% in the oncology and hemato-oncology wards, and only 2% in the neurology ward. In 61.6% of hospitalizations fulfilling the criteria, the underlying reason was cancer, and in 41.5% it was other chronic diseases (see Table 1). Eighteen hospitalizations fullfilled the criteria for both cancer and another underlying chronic disease. Compared with all the patients admitted to the internal medicine division, the study population was older, with a significantly higher proportion above 75 years of age (51.9% versus 29.8%, p < 0.001); had a longer mean duration of hospitalization (5.95 versus 5.06 days); and had a higher mortality rate during their hospital stay (14% versus 6%, p < 0.001). The inhospital mortality rate was higher in hospitalizations of patients with noncancer indications for palliative care (17%) than in patients with cancer (5.4%, p < 0.001). Patients whose main complaint at admission was general deterioration or decrease in appetite had a higher rate of inhospital death (23.4% and 30.7%, respectively). Infection was the primary diagnosis in almost half of the hospitalizations ending in death (47.8%), compared to only 29.9% where the patient survived. Arrangements for palliative care were made for only 12 (3.5%) of the patients discharged—home hospice unit for 10
791
Table 1. Distribution of Underlying Cause by Caring Criteria (N = 347 Patients) CARING criteria Primary diagnosis of Cancer Met the Noncancer hospice Guidelines End-stage pulmonary disease Alzheimer’s and other causes of dementia Adult failure to thrive Cerebrovascular disease End-stage hepatic disease End-stage renal disease End-stage cardiac disease Amyotrophic lateral sclerosis (ALS)
Of 417 admissions, % (#) 61.6% (257) 41.5% (173) 46.2% (80/173) 22.5% (39/173) 13.3% 5.8% 5.2% 4.6% 3.5% 0.5%
(23/173) (10/173) (9/173) (8/173) (6/173) (1/173)
patients and home care unit for 2 patients. Cancer was the underlying indication in all of these. Of these, mortalityrelated data were obtained over a six month follow-up period for eight, all of whom died. We also obtained mortality-related data for this six-month follow-up period for 86.7% of the overall study population (301/347 patients). Of these, 142/301 (47%) died during this period. This was more than five times higher than the death rate for all the patients hospitalized in the internal medicine division (1503 deaths, 9.12%, p < 0.001). The mean period from hospitalization to death was 48 days (range 0–179 days) in the study population. Living in a nursing home prior to admission was significantly associated with death in the follow-up period—74%, compared to 42.5% of patients living in their own home or a family member’s home ( p < 0.001). Other sociodemographic data including gender, age, marital status, number of children, and country of birth were not significantly different. Discussion
As expected, in admissions with a CARING score ‡13, the main underlying cause was cancer, although a noteworthy proportion was due to other chronic end-stage diseases, mainly end-stage pulmonary disease, Alzheimer’s, and adult failure to thrive. Identifying patients at the time of hospital admission who are at high risk for one-year mortality is an ideal opportunity to introduce palliative interventions. The CARING criteria are a practical prognostic tool validated in a broad inpatient population and could be utilized as a screening tool to identify patients at admission, and as a basis for their referral for a palliative care consultation.14,16 This was the main stated objective in the design of these criteria.14 There are other prognostic tools, 6,17 but they usually require detailed information that is not readily available in the clinical setting, or they were developed based on critically ill patients rather than the general medicine ward patients.14 Some may claim that CARING is not the optimal tool in the geriatric population and due to the dynamic nature of patient’s health at this age that clinical judgment should also be taken into account. However it should be mentioned that these criteria use the NHPCO guidelines15 and were also validated in medical wards of general hospitals.16
792
In the original CARING criteria study,14 one-year mortality was used as the endpoint, and it was concluded that those having a score ‡13 had a probability of death ‡0.49. Our study supports these findings. Since follow-up data were available for only 87% of the patients and for a time period limited to six months, it is reasonable to assume that an even higher percent of patients died over the year following hospitalization. Due to the retrospective nature of this study, and in order to fully identify all patients in need of palliative care, we collected all data available from the patient’s entire medical file and not only at admission (the original designation of the CARING criteria). Furthermore, some of the clinical criteria that appear in the NHPCO guidelines were not addressed in the admission file. This shortcoming in our study design could be addressed in ‘‘real’’ life, if the CARING criteria were integrated into the routine admission forms. The integration of a palliative care unit in the acute care setting has been studied in the past. The evidence suggested that palliative care can reduce hospitalization length18 and costs.19–22 Our study lacked data to identify patients whose needs could be fulfilled by a palliative expert consultation alone compared to those requiring a higher level of palliative care, in a dedicated inpatient unit. Likewise, data on patients not fulfilling the CARING criteria were not extracted, so that the two groups could not be effectively compared. Further research is needed to address these issues. The retrospective nature of data collection in our study is another weakness. Furthermore, the medical files in SUMC are still mostly handwritten, suggesting the possibility of missing data and misinterpretation. If more carefully recorded data had been available, some additional patients might have had a CARING score ‡13. Thus, the actual percentage of patients in need of palliative care may be even higher. Strengths of this study are the large sample size and the fact that the data were extracted throughout the year, so that seasonal differences were controlled for. The simple screening tool used in this study could be applied easily in clinical settings, and the data suggest that these criteria are effective in the identification of patients in need of palliative care. Author Disclosure Statement
No competing financial interests exist for any of the authors. We received funding of $5,000 through the Goldman Fund of the Faculty of Health Sciences, Ben-Gurion University of the Negev. References
1. Chou W-C, Lai Y-T, Huang Y-C, et al.: Comparing end of life care for hospitalized patients with chronic obstructive pulmonary disease and lung cancer in Taiwan. J Palliat Care 2013;29:29–35. 2. Formiga F, Espel E, Chivite D, et al.: Dying from heart failure in hospital: Palliative decision making analysis. Heart 2002;88:187.
BAR-ZE’EV ET AL.
3. Sloan RH: Cancer isn’t the only malignant disease: Palliative care can be useful in cardiovascular disease. BMJ 2002;324:1035–1036. 4. Hanratty B, Hibbert D, Mair F, et al: Doctors’ perceptions of palliative care for heart failure: Focus group study. BMJ 2002;325:581–585. 5. Murtagh FE, Preston M, Higginson I: Patterns of dying: Palliative care for nonmalignant disease. Clin Med 2004;4:39–44. 6. Knaus WA, Harrell FE Jr., Lynn J, et al.: The SUPPORT prognostic model: Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risk of treatments. Ann Intern Med 1995;122:191–203. 7. Giacomini M, DeJean D, Simeonov D, et al.: Experiences of living and dying with COPD: A systematic review and synthesis of the qualitative empirical literature. Ont Health Technol Assess Ser 2012;12:1–47. 8. Fox E, Landrum-Mcniff K, Zhong Z, et al.: Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart or liver disease: SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. JAMA 1999;282:1638–1645. 9. National Hospice and Palliative Care Organization: NHPCO’s Facts and Figures: Hospice Care in America. National Hospice and Palliative Care Organization, 2013. www.nhpco.org/sites/default/files/public/Statistics_Research/ 2013_Facts_Figures.pdf. (Last accessed July 24, 2014.) 10. Israel Central Bureau of Statistics: Mortality and life expectancy tables. Israel Central Bureau of Statistics. www .cbs.gov.il. (Last accessed November 14, 2014.) 11. Israel Ministry of Health: Recommendations of the Committee for Development of Guidelines for the Setting of Palliative Services in Israel. Israel Ministry of Health, 2005. 12. Bentur N, Resnizky S, Shnoor Y: Palliative and Hospice Services in Israel. Myers-JDC-Brookdale Institute, 2005. brookdale.jdc.org.il/?CategoryID = 192&ArticleID = 106. (Last accessed July 24, 2014.) 13. Israel Ministry of Health: Directive General Circular #30/ 09: Operating a palliative service (hospice) in the community, general hospital and nursing home. Israel Ministry of Health, 2009. 14. Fischer SM, Gozansky WS, Sauaia A, et al.: A practical tool to identify patients who may benefit from a palliative approach: The CARING criteria. J Pain Symptom Manage 2006;31:285–292. 15. National Hospice and Palliative Care Organization Guidelines. 1996. www.nhpco.org. (Last accessed July 24, 2014.) 16. Youngwert J, Min Sj, Statland B, et al.: Caring about prognosis: A validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year. J Hosp Med 2013;8:696–701. 17. Lee SJ, Lindquist KL, Segal MR, et al.: Development and validation of a prognostic index for 4 year mortality in older adults. JAMA 2006;295:801–808. 18. Finlay IG, Higginson IJ, Goodwin DM, et al.: Palliative care in hospital, hospice, at home: Results from a systematic review. Ann Oncol 2002;13:257–264. 19. Smith T: Adding hospice and palliative care services to the cancer center menu. J Palliat Med 2003;6:641–644.
HOSPITAL PALLIATIVE CARE
20. Morrison RS, Dietrich J, Ladwig S, et al.: Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood) 2011;30:454–463. 21. Morrison RS, Penrod JD, Cassel JB, et al.: Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168:1783–1790. 22. Albanese TH, Radwany SM, Mason H, et al: Assessing the financial impact of an inpatient acute palliative care unit in a tertiary care teaching hospital. J Palliat Med 2013;16:289–294.
793
Address correspondence to: Pesach Shvartzman, MD Pain and Palliative Medicine Unit Ben-Gurion University of the Negev POB 653 Beer-Sheva, Israel 84105 E-mail: [email protected]
Evaluating the Need for Palliative Care Services at a General Hospital in Israel Yael Bar-Ze’ev, MD, MPH,1 Yoram Singer, MD,2 and Pesach Shvartzman, MD1,2
Abstract
Background: Most hospitals in Israel do not provide palliative care beds and only few general hospitals have palliative consultation services. To date there are no data on the rate of hospitalizations and the need for palliative care in general hospitals in Israel. Objective: The objective was to characterize patients in need of palliative treatment during hospitalization in a general hospital in Israel. Methods: A retrospective review was performed of a random sample of files of patients admitted to the Internal Medicine Department at the Soroka University Medical Center (SUMC) between May 2007 and April 2008. Patients were defined as in need of palliative care if they had a CARING score ‡13. The data were collected using a structured questionnaire that included sociodemographic data and data on comorbid conditions, main complaints, primary diagnosis, duration of hospitalization, and hospitalization outcome. Results: We reviewed 2795 hospitalizations. Of these, 14.9% were defined as in need of palliative care. Fourteen percent of the patients died during hospitalization and 47% died over the six-month follow-up period. The most common primary diagnosis was malignancy (61%), followed by end-stage pulmonary disease (19%) and Alzheimer’s and other causes of dementia (9%). In only 12 hospitalizations (3.5%) was palliative care arranged for patients at discharge. Conclusions: A high percentage of patients hospitalized in internal medicine divisions could benefit from palliative care. The data presented here could aid hospitals in the integration of palliative care services.
Introduction
T
here is general agreement that palliative treatment is needed for cancer patients, and over time the need for palliative treatment for patients at the end stage of other illnesses1–9 has been recognized increasingly. In Israel, 41,600 people die each year according to data from 2013.10 Only about 10% of patients who required palliative care services actually had access to it.11–12 Most hospitals in Israel do not have any palliative care service. A few general hospitals have palliative consultation services, and there are only two general hospitals with beds specifically dedicated to palliative care.11 The Israel Ministry of Health has made clear recommendations for access to palliative care services.13 One of the recommendations was to provide palliative care services wherever the patient prefers to stay, including general hospitals. To date there are no data on the rate of hospitalization of patients who require palliative care in general hospitals in
Israel. In the present study we collected preliminary data on the extent of the problem and its characteristics. This will provide support information to aid in the planning and evaluation of palliative care services in Israel and could also serve as an aid to other countries facing similar challenges. Methods
The study was conducted at the Soroka University Medical Center (SUMC), the only general hospital in the southern region of Israel, serving a population of 900,000. The study included a retrospective review of a random sample of admissions to seven internal medicine wards, one neurology ward, one oncology ward, and one hemato-oncology ward between May 1, 2007 and April 30, 2008. Fourteen months of hospitalizations were reviewed (10 months in internal medicine departments, 2 in neurology, 2 in oncology and 1 in hemato-oncology). The CARING criteria, a screening tool aimed at identifing patients who may benefit from palliative care,14 were used.
1 Sial Family Medicine and Primary Care Research Center, Division of Community Health, 2Pain and Palliative Care Unit, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel. Accepted May 19, 2015.
790
HOSPITAL PALLIATIVE CARE
These criteria, which use the National Hospice and Palliative Care Organization (NHPCO) guidelines,15 include several items: C-primary diagnosis of Cancer (10 points) A- ‡ 2 Admissions to the hospital for a chronic illness within the last year (3 points) R-Resident in a nursing home (3 points) I-Intensive care unit admission with multiorgan failure (10 points) N-Noncancer hospice (meeting ‡2 of the NHPCO (12 points) G-Guidelines The final score incorperates a different weight for each item, also taking into account the age of the patient (75, 3 points). Each hospital record was reviewed using a structured questionnaire that included the CARING criteria. Patients with a CARING score ‡13 were defined as in need of palliative care, and further data were collected, including sociodemographic data, comorbidity, main complaints, primary diagnosis, duration of hospitalization, and hospitalization outcome. For comparison we extracted data for all patients hospitalized during the study period in the internal medicine division from the computerized files of the SUMC (linked to the Population Reference Bureau, Ministry of Interior, Israel). The available data included age, gender, mean duration of hospitalization, and date of death (if relevant). Results
We randomly reviewed 2795 hospitalizations from 25,911 admissions of 16,981 patients. The CARING criteria were fulfilled by 417 (14.9%) of the hospitalizations (347 patients, as we included repeated admissions during the study period). In internal medicine wards, 14.8% of hospitalizations fulfilled the criteria, compared to nearly 50% in the oncology and hemato-oncology wards, and only 2% in the neurology ward. In 61.6% of hospitalizations fulfilling the criteria, the underlying reason was cancer, and in 41.5% it was other chronic diseases (see Table 1). Eighteen hospitalizations fullfilled the criteria for both cancer and another underlying chronic disease. Compared with all the patients admitted to the internal medicine division, the study population was older, with a significantly higher proportion above 75 years of age (51.9% versus 29.8%, p < 0.001); had a longer mean duration of hospitalization (5.95 versus 5.06 days); and had a higher mortality rate during their hospital stay (14% versus 6%, p < 0.001). The inhospital mortality rate was higher in hospitalizations of patients with noncancer indications for palliative care (17%) than in patients with cancer (5.4%, p < 0.001). Patients whose main complaint at admission was general deterioration or decrease in appetite had a higher rate of inhospital death (23.4% and 30.7%, respectively). Infection was the primary diagnosis in almost half of the hospitalizations ending in death (47.8%), compared to only 29.9% where the patient survived. Arrangements for palliative care were made for only 12 (3.5%) of the patients discharged—home hospice unit for 10
791
Table 1. Distribution of Underlying Cause by Caring Criteria (N = 347 Patients) CARING criteria Primary diagnosis of Cancer Met the Noncancer hospice Guidelines End-stage pulmonary disease Alzheimer’s and other causes of dementia Adult failure to thrive Cerebrovascular disease End-stage hepatic disease End-stage renal disease End-stage cardiac disease Amyotrophic lateral sclerosis (ALS)
Of 417 admissions, % (#) 61.6% (257) 41.5% (173) 46.2% (80/173) 22.5% (39/173) 13.3% 5.8% 5.2% 4.6% 3.5% 0.5%
(23/173) (10/173) (9/173) (8/173) (6/173) (1/173)
patients and home care unit for 2 patients. Cancer was the underlying indication in all of these. Of these, mortalityrelated data were obtained over a six month follow-up period for eight, all of whom died. We also obtained mortality-related data for this six-month follow-up period for 86.7% of the overall study population (301/347 patients). Of these, 142/301 (47%) died during this period. This was more than five times higher than the death rate for all the patients hospitalized in the internal medicine division (1503 deaths, 9.12%, p < 0.001). The mean period from hospitalization to death was 48 days (range 0–179 days) in the study population. Living in a nursing home prior to admission was significantly associated with death in the follow-up period—74%, compared to 42.5% of patients living in their own home or a family member’s home ( p < 0.001). Other sociodemographic data including gender, age, marital status, number of children, and country of birth were not significantly different. Discussion
As expected, in admissions with a CARING score ‡13, the main underlying cause was cancer, although a noteworthy proportion was due to other chronic end-stage diseases, mainly end-stage pulmonary disease, Alzheimer’s, and adult failure to thrive. Identifying patients at the time of hospital admission who are at high risk for one-year mortality is an ideal opportunity to introduce palliative interventions. The CARING criteria are a practical prognostic tool validated in a broad inpatient population and could be utilized as a screening tool to identify patients at admission, and as a basis for their referral for a palliative care consultation.14,16 This was the main stated objective in the design of these criteria.14 There are other prognostic tools, 6,17 but they usually require detailed information that is not readily available in the clinical setting, or they were developed based on critically ill patients rather than the general medicine ward patients.14 Some may claim that CARING is not the optimal tool in the geriatric population and due to the dynamic nature of patient’s health at this age that clinical judgment should also be taken into account. However it should be mentioned that these criteria use the NHPCO guidelines15 and were also validated in medical wards of general hospitals.16
792
In the original CARING criteria study,14 one-year mortality was used as the endpoint, and it was concluded that those having a score ‡13 had a probability of death ‡0.49. Our study supports these findings. Since follow-up data were available for only 87% of the patients and for a time period limited to six months, it is reasonable to assume that an even higher percent of patients died over the year following hospitalization. Due to the retrospective nature of this study, and in order to fully identify all patients in need of palliative care, we collected all data available from the patient’s entire medical file and not only at admission (the original designation of the CARING criteria). Furthermore, some of the clinical criteria that appear in the NHPCO guidelines were not addressed in the admission file. This shortcoming in our study design could be addressed in ‘‘real’’ life, if the CARING criteria were integrated into the routine admission forms. The integration of a palliative care unit in the acute care setting has been studied in the past. The evidence suggested that palliative care can reduce hospitalization length18 and costs.19–22 Our study lacked data to identify patients whose needs could be fulfilled by a palliative expert consultation alone compared to those requiring a higher level of palliative care, in a dedicated inpatient unit. Likewise, data on patients not fulfilling the CARING criteria were not extracted, so that the two groups could not be effectively compared. Further research is needed to address these issues. The retrospective nature of data collection in our study is another weakness. Furthermore, the medical files in SUMC are still mostly handwritten, suggesting the possibility of missing data and misinterpretation. If more carefully recorded data had been available, some additional patients might have had a CARING score ‡13. Thus, the actual percentage of patients in need of palliative care may be even higher. Strengths of this study are the large sample size and the fact that the data were extracted throughout the year, so that seasonal differences were controlled for. The simple screening tool used in this study could be applied easily in clinical settings, and the data suggest that these criteria are effective in the identification of patients in need of palliative care. Author Disclosure Statement
No competing financial interests exist for any of the authors. We received funding of $5,000 through the Goldman Fund of the Faculty of Health Sciences, Ben-Gurion University of the Negev. References
1. Chou W-C, Lai Y-T, Huang Y-C, et al.: Comparing end of life care for hospitalized patients with chronic obstructive pulmonary disease and lung cancer in Taiwan. J Palliat Care 2013;29:29–35. 2. Formiga F, Espel E, Chivite D, et al.: Dying from heart failure in hospital: Palliative decision making analysis. Heart 2002;88:187.
BAR-ZE’EV ET AL.
3. Sloan RH: Cancer isn’t the only malignant disease: Palliative care can be useful in cardiovascular disease. BMJ 2002;324:1035–1036. 4. Hanratty B, Hibbert D, Mair F, et al: Doctors’ perceptions of palliative care for heart failure: Focus group study. BMJ 2002;325:581–585. 5. Murtagh FE, Preston M, Higginson I: Patterns of dying: Palliative care for nonmalignant disease. Clin Med 2004;4:39–44. 6. Knaus WA, Harrell FE Jr., Lynn J, et al.: The SUPPORT prognostic model: Objective estimates of survival for seriously ill hospitalized adults. Study to understand prognoses and preferences for outcomes and risk of treatments. Ann Intern Med 1995;122:191–203. 7. Giacomini M, DeJean D, Simeonov D, et al.: Experiences of living and dying with COPD: A systematic review and synthesis of the qualitative empirical literature. Ont Health Technol Assess Ser 2012;12:1–47. 8. Fox E, Landrum-Mcniff K, Zhong Z, et al.: Evaluation of prognostic criteria for determining hospice eligibility in patients with advanced lung, heart or liver disease: SUPPORT Investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. JAMA 1999;282:1638–1645. 9. National Hospice and Palliative Care Organization: NHPCO’s Facts and Figures: Hospice Care in America. National Hospice and Palliative Care Organization, 2013. www.nhpco.org/sites/default/files/public/Statistics_Research/ 2013_Facts_Figures.pdf. (Last accessed July 24, 2014.) 10. Israel Central Bureau of Statistics: Mortality and life expectancy tables. Israel Central Bureau of Statistics. www .cbs.gov.il. (Last accessed November 14, 2014.) 11. Israel Ministry of Health: Recommendations of the Committee for Development of Guidelines for the Setting of Palliative Services in Israel. Israel Ministry of Health, 2005. 12. Bentur N, Resnizky S, Shnoor Y: Palliative and Hospice Services in Israel. Myers-JDC-Brookdale Institute, 2005. brookdale.jdc.org.il/?CategoryID = 192&ArticleID = 106. (Last accessed July 24, 2014.) 13. Israel Ministry of Health: Directive General Circular #30/ 09: Operating a palliative service (hospice) in the community, general hospital and nursing home. Israel Ministry of Health, 2009. 14. Fischer SM, Gozansky WS, Sauaia A, et al.: A practical tool to identify patients who may benefit from a palliative approach: The CARING criteria. J Pain Symptom Manage 2006;31:285–292. 15. National Hospice and Palliative Care Organization Guidelines. 1996. www.nhpco.org. (Last accessed July 24, 2014.) 16. Youngwert J, Min Sj, Statland B, et al.: Caring about prognosis: A validation study of the caring criteria to identify hospitalized patients at high risk for death at 1 year. J Hosp Med 2013;8:696–701. 17. Lee SJ, Lindquist KL, Segal MR, et al.: Development and validation of a prognostic index for 4 year mortality in older adults. JAMA 2006;295:801–808. 18. Finlay IG, Higginson IJ, Goodwin DM, et al.: Palliative care in hospital, hospice, at home: Results from a systematic review. Ann Oncol 2002;13:257–264. 19. Smith T: Adding hospice and palliative care services to the cancer center menu. J Palliat Med 2003;6:641–644.
HOSPITAL PALLIATIVE CARE
20. Morrison RS, Dietrich J, Ladwig S, et al.: Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood) 2011;30:454–463. 21. Morrison RS, Penrod JD, Cassel JB, et al.: Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med 2008;168:1783–1790. 22. Albanese TH, Radwany SM, Mason H, et al: Assessing the financial impact of an inpatient acute palliative care unit in a tertiary care teaching hospital. J Palliat Med 2013;16:289–294.
793
Address correspondence to: Pesach Shvartzman, MD Pain and Palliative Medicine Unit Ben-Gurion University of the Negev POB 653 Beer-Sheva, Israel 84105 E-mail: [email protected]
