Section Editor
®
WriteClick Editor’s Choice
Robert C. Griggs, MD
Editors’ Note: Commenting on the palliative care article by Boersma et al., Gillum, a neurologist and daughter of a patient with Alzheimer disease, critiques the criteria neurologic patients must meet to be admitted into hospice. Drs. Kluger and Miyasaki respond. Because of the shortage of neurologists in India, Singh suggests that some neurologic disorders should be managed by providers other than neurologists. Mehndiratta et al. do not completely agree with this suggestion and express their opinion. —Chafic Karam, MD, and Robert C. Griggs, MD
PALLIATIVE CARE AND NEUROLOGY: TIME FOR A PARADIGM SHIFT
Leslie A. Gillum, Pleasant Hill, CA: I thank Boersma et al.1 for their article on palliative care. As a neurologist and daughter of a patient with Alzheimer disease, I am appalled at the criteria neurologic patients must “achieve” to be admitted into hospice.2 For cancer patients to qualify for hospice, the criteria include severe and worsening disease, treatments exhausted or refused, and a palliative performance score (PPS) less than 70%. Supportive—but not required— documentation includes weight loss greater than 5% in 3 months and signs and symptoms of recurrent or advanced disease. For patients with dementia, the criteria include loss of ambulation and secondary comorbidities such as aspiration pneumonia, pyelonephritis, and weight loss greater than 10% in 6 months. For stroke patients, the criteria include PPS less than 40% and poor nutritional status including 7.5% weight loss in 3 months. What rationale could there possibly be for these obvious disparities? It is neither humane nor ethical. It is particularly nonsensical when data suggest lower cost of care for neurologic hospice patients.3 As the United States looks toward dramatically increasing dementia prevalence with starkly diminishing health care dollars available per citizen, addressing the hospice criteria for neurologic patients should be treated as a health care emergency. Author Response: Benzi M. Kluger, Aurora, CO; Janis Miyasaki, Edmonton, Canada: The authors 1184
Neurology 84
thank Dr. Gillum for her comments, which speak to the heart of one of the most pressing palliative care issues in neurology. Differences in hospice criteria contribute to disparities in hospice services between cancer and neurologic patients. From a scientific perspective, the problem lies in predicting time to death in neurologic disease. With the possible exception of motor neuron disease, there are very little data available to help neurologists to predict disease course and prompt the need for clinical research. From an educational perspective, neurologists need to think about hospice earlier, develop skills to communicate the potential benefits of this option to patients, advocate for their patients, and collaborate with colleagues in palliative care to improve end-oflife care for their complex patients. We also need policymakers to understand the tremendous financial and emotional costs of our current care model, which places an undue burden on a silent workforce of family and informal caregivers and overutilizes emergency and intensive care services. There is a significant need and opportunity for clinicians, researchers, policymakers, and patient advocates to make a difference in end-of-life outcomes for patients with advanced neurologic disease. © 2015 American Academy of Neurology 1.
2.
3.
Boersma I, Miyasaki J, Kutner J, Kluger B. Palliative care and neurology: time for a paradigm shift. Neurology 2014; 83:561–567. Stuart B, Alexander C, Arenella C. Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, 2nd ed. Arlington, VA: National Hospice Organization; 1996. Higginson IJ, McCrone P, Hart SR, et al. Is short-term palliative care cost-effective in multiple sclerosis? A randomized phase II trial. J Pain Symptom Manage 2009;38:816–826.
HETEROGENEITY IN NEUROLOGIC EDUCATION AND CARE IN ASIAN AND OCEANIAN REGION
Mamta Bhushan Singh, New Delhi: Mehndiratta et al.1 highlighted the resource imbalance between developed and developing countries. While lowand middle-income countries are densely populated with high patient numbers, high-income countries have more resources to treat their relatively small number of patients with neurologic illnesses. Multiple
March 17, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Palliative care and neurology: Time for a paradigm shift Leslie A. Gillum, Benzi M. Kluger and Janis Miyasaki Neurology 2015;84;1184 DOI 10.1212/WNL.0000000000001384 This information is current as of March 16, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/11/1184.1.full.html
References
This article cites 2 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/11/1184.1.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
®
WriteClick Editor’s Choice
Robert C. Griggs, MD
Editors’ Note: Commenting on the palliative care article by Boersma et al., Gillum, a neurologist and daughter of a patient with Alzheimer disease, critiques the criteria neurologic patients must meet to be admitted into hospice. Drs. Kluger and Miyasaki respond. Because of the shortage of neurologists in India, Singh suggests that some neurologic disorders should be managed by providers other than neurologists. Mehndiratta et al. do not completely agree with this suggestion and express their opinion. —Chafic Karam, MD, and Robert C. Griggs, MD
PALLIATIVE CARE AND NEUROLOGY: TIME FOR A PARADIGM SHIFT
Leslie A. Gillum, Pleasant Hill, CA: I thank Boersma et al.1 for their article on palliative care. As a neurologist and daughter of a patient with Alzheimer disease, I am appalled at the criteria neurologic patients must “achieve” to be admitted into hospice.2 For cancer patients to qualify for hospice, the criteria include severe and worsening disease, treatments exhausted or refused, and a palliative performance score (PPS) less than 70%. Supportive—but not required— documentation includes weight loss greater than 5% in 3 months and signs and symptoms of recurrent or advanced disease. For patients with dementia, the criteria include loss of ambulation and secondary comorbidities such as aspiration pneumonia, pyelonephritis, and weight loss greater than 10% in 6 months. For stroke patients, the criteria include PPS less than 40% and poor nutritional status including 7.5% weight loss in 3 months. What rationale could there possibly be for these obvious disparities? It is neither humane nor ethical. It is particularly nonsensical when data suggest lower cost of care for neurologic hospice patients.3 As the United States looks toward dramatically increasing dementia prevalence with starkly diminishing health care dollars available per citizen, addressing the hospice criteria for neurologic patients should be treated as a health care emergency. Author Response: Benzi M. Kluger, Aurora, CO; Janis Miyasaki, Edmonton, Canada: The authors 1184
Neurology 84
thank Dr. Gillum for her comments, which speak to the heart of one of the most pressing palliative care issues in neurology. Differences in hospice criteria contribute to disparities in hospice services between cancer and neurologic patients. From a scientific perspective, the problem lies in predicting time to death in neurologic disease. With the possible exception of motor neuron disease, there are very little data available to help neurologists to predict disease course and prompt the need for clinical research. From an educational perspective, neurologists need to think about hospice earlier, develop skills to communicate the potential benefits of this option to patients, advocate for their patients, and collaborate with colleagues in palliative care to improve end-oflife care for their complex patients. We also need policymakers to understand the tremendous financial and emotional costs of our current care model, which places an undue burden on a silent workforce of family and informal caregivers and overutilizes emergency and intensive care services. There is a significant need and opportunity for clinicians, researchers, policymakers, and patient advocates to make a difference in end-of-life outcomes for patients with advanced neurologic disease. © 2015 American Academy of Neurology 1.
2.
3.
Boersma I, Miyasaki J, Kutner J, Kluger B. Palliative care and neurology: time for a paradigm shift. Neurology 2014; 83:561–567. Stuart B, Alexander C, Arenella C. Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases, 2nd ed. Arlington, VA: National Hospice Organization; 1996. Higginson IJ, McCrone P, Hart SR, et al. Is short-term palliative care cost-effective in multiple sclerosis? A randomized phase II trial. J Pain Symptom Manage 2009;38:816–826.
HETEROGENEITY IN NEUROLOGIC EDUCATION AND CARE IN ASIAN AND OCEANIAN REGION
Mamta Bhushan Singh, New Delhi: Mehndiratta et al.1 highlighted the resource imbalance between developed and developing countries. While lowand middle-income countries are densely populated with high patient numbers, high-income countries have more resources to treat their relatively small number of patients with neurologic illnesses. Multiple
March 17, 2015
ª 2015 American Academy of Neurology. Unauthorized reproduction of this article is prohibited.
Palliative care and neurology: Time for a paradigm shift Leslie A. Gillum, Benzi M. Kluger and Janis Miyasaki Neurology 2015;84;1184 DOI 10.1212/WNL.0000000000001384 This information is current as of March 16, 2015 Updated Information & Services
including high resolution figures, can be found at: http://www.neurology.org/content/84/11/1184.1.full.html
References
This article cites 2 articles, 1 of which you can access for free at: http://www.neurology.org/content/84/11/1184.1.full.html##ref-list-1
Permissions & Licensing
Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions
Reprints
Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus
Neurology ® is the official journal of the American Academy of Neurology. Published continuously since 1951, it is now a weekly with 48 issues per year. Copyright © 2015 American Academy of Neurology. All rights reserved. Print ISSN: 0028-3878. Online ISSN: 1526-632X.
