Attitudes Toward Hospice Care

LETTERS TO THE EDITOR BASIC STANDARDS FOR PHYSICIANS IN LONG-TERM CARE I have been a medical director since 1986 and am grateful for the expertise I have developed through my involvement with the American Medical directors Association (AMDA) and the California Association of Long-Term Care Medicine (CAL-TCM). Our work is done in a highly regulated environment, and our patients’ problems are multifaceted and complex. Unfortunately, most of my colleagues, even the medical directors, seem complacent about their lack of knowledge in these areas. Sadly, as I look around my community, only one of five medical directors has ever attended a CAL-TCM continuing medical education (CME) program, and none have attended an AMDA CME program. I have sent them brochures for these CME opportunities for many years. When I have talked with them directly, I usually hear excuses “I’m too busy,” or “the meetings are too expensive,” or “the DON tells me what to do.” These excuses produce continued mediocre medical services and waste scarce resources for skilled nursing facility (SNF) care. Two states have recently established basic standards for medical directors. In Maryland, the state medical directors association worked with the Department of Health Services (DHS) to develop standards not only for medical directors, but also for attending physicians. For the medical directors, they would have 3 years to become certified by AMDA. This seems like a very reasonable requirement. It provides incentive for the medical directors to develop the basic competencies to be effective in their roles, and it also encourages the facilities to help finance the CME. The regulations for attending physicians are less rigorous, but do affect MDs’ licenses, should they fail to comply with the federal and state regulations. This gives further incentive to those doing long-term care work to know the regulations and comply with them. In my role as medical director, I would then be able to spend more time on education, and less on creatively enforcing the regulations. I know that many people are concerned about having more regulations. They say we are already over “regulated,” and that regulations such as the “Maryland ones” will drive physicians out of long-term care (LTC). While this may be true in areas that are underserved by physicians, in the majority of our communities, this is probably not the case. Once physicians in LTC become more aware of the medical science of LTC and the reasons for the regulations, I think they will have a greater interest and enjoyment in caring and advocating for their LTC patients. I urge AMDA and the state associations, to consider advocating for a basic set of competencies for medical directors and attending physicians. Tim L. Gieseke, MD, CMD Santa Rosa, California. LETTERS TO THE EDITOR

ATTITUDES TOWARD HOSPICE CARE We designed and pilot tested a survey to explore how nursing home physicians and hospice staff perceive hospice use in the nursing home. A convenience sample of nursing home, hospice, and hospital-affiliated personnel and physicians, primarily in Maryland, North Carolina, Oklahoma, Michigan, and California, were asked to complete a survey questionnaire regarding hospice care in nursing homes. The questionnaire addresses whether nursing homes provide the same end-of-life care as hospice services provide, whether there are perceived problems in communication or cooperation between hospices and nursing homes, and what, if anything, contributes to the effectiveness of hospices in nursing homes. Questions were primarily formulated for dichotomous agreement or disagreement, although two questions offered multiple response options. Differences in the responses were statistically analyzed using chi-square tests to compare responses by professional role. Written comments were transcribed and categorized. A total of 250 responses were obtained, of which 101 were from physicians, including 48 medical directors. The responses from the medical directors were similar to responses from hospice personnel and nursing home personnel. The respondents uniformly felt that hospice makes a difference, and the nursing home cannot do the same quality of care without hospice. All the professions who responded, whether nursing home medical directors with or without hospice affiliation, or hospice employees, shared this attitude. The respondents also agreed that there are still some issues with integrating hospice into nursing homes, especially with meshing the different cultures and getting good communication. We conclude from this pilot study that nursing home medical directors generally have positive attitudes towards hospice services in the nursing home that are very similar to the attitudes of hospice personnel. It is unlikely that medical directors are a major barrier to implementation of hospice services. Timothy J. Keay, MD, MA-Th, CMD Department of Family Medicine, University of Maryland School of Medicine Kerry Cranmer, MD, CMD Department of Family Medicine, University of Oklahoma School of Medicine Laura Hanson, MD Department of Medicine, University of North Carolina, Chapel Hill. 121