2014 ppe disclosure statement
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2014 PPE Disclosure Statement. - PowerPoint PPT PresentationTRANSCRIPT
2014 PPEDisclosure Statement
It is the policy of the Oregon Hospice Association to insure balance, independence, objectivity, and scientific rigor in all its educational programs. All faculty participating in any Oregon Hospice Association program is expected to disclose to the program audience any real or apparent affiliation(s) that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker from making a presentation. It is merely intended that any relationships should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
This presenter has no significant relationships with companies relevant to this presentation to disclose.
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An Interactive Discussion to Add Your Voice and Experience to Oregon's StoryOHA’s 2014 PPE, Bend Oregon
September 30, 2014Death With Dignity in the Laboratory of Oregon
Ann Jackson, [email protected] www.ann-jackson.com
Hastening Death & Hospice: Lessons from the Front Line
October 18, 2007Professional Practices ExchangeOregon Hospice AssociationGrants Pass, Oregon Ann Jackson, MBAOregon Hospice Associationwww.oregonhospice.org
Ann Jackson Consultant re end-of-life issues and options CEO Oregon Hospice Association (1988-
2008) MBA in nonprofit management Co-investigator in studies looking at
hospice workers’ experiences with hastening death
Speaker re EOL care in Oregon Member of Oregon and national task forces
re hospice and EOL Hospice caregiver
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Goal
Provide forum for Oregon’s hospice workers to discuss and share experiences, observations, and concerns about our “laboratory of the states”
Objectives This session will offer participants conceptual, actual,
and practical experience to be able, in the future, to effect the following: Discuss openly and honestly controversial topics , such
as PAD and hastening death; Consider practical implications of data collection and
research about the DWDA and the potential application in the field of curative or palliative care and hospice;
Provide platform to evaluate or reassess hospice policies and practices related to hastening death and revise or modify as indicated;
Create strategies to remove perceived or real barriers to hospice and other end of life options;
Support and participate in future research.
Objectives (2007) Consider trends and implications of data
related to ODDA and hospice utilizationDiscuss openly and honestly controversial
topic in safe and confidential environmentShare policies and practices related to
hastening deathIdentify perceived/real barriers to Oregon’s
legal end of life optionsOffer topics for future research
PurposeAdd experience-based
information Close data void “Laboratory of the states”
Not defend DWDA Not debate whether physician
assisted dying is right or wrong
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No longer matters whether PAD is right or wrong.
Allowable in state. Dying Oregonians may choose from
among all EOL options, including hospice and DWDA.
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PAD Legal Option in Oregon
Content Summary Predicted and actual outcomes of
PAD in Oregon Characteristics of PAD deaths Hospice response to DWDA
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History of DWDA/PAD Citizen’s initiative 11/94 (51% to 49%) Injunction 12/94 Injunction lifted 10/97 Repeal referendum defeated 11/97 (60% to 40%) DEA threatens physicians 11/97 Reno reversal 4/98 Ashcroft re-reversal 11/01 TRO 11/01 PRO 4/02 9th Circuit Court panel rules in favor of Oregon 6/04 Ashcroft appeals 9th Circuit Court panel decision 7/04 9th Circuit Court “en banc” refuses request 9/04 Ashcroft appeals to US Supreme Court 11/04 US Supreme Court agrees to hear Gonzales vs Oregon 2/05 US Supreme Court oral arguments heard in 10/05 US Supreme Court rules in favor of Oregon 1/06 Senator Brownback introduces Assisted Suicide Prevention Act 8/06 Jack Kevorkian released from 8 years of prison 6/07 Washington State initiative 11/08 (59% to 41%) Montana court rules in favor of constitutional right 11/08 and rejects stay 1/09 Washington Death With Dignity Act implemented 3/09 Montana Supreme Court says state law does not forbid physician-aid-in dying 12/31/09 Montana’s Legislature defeats bills to make PAD illegal and to develop legal parameters 2/2011 Vermont Governor Shumin signs first PAD law to be enacted through legislation on 5/20/2013
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History of DWDA (2007) • Citizen’s initiative 11/94 (51% to 49%)• Injunction 12/94• Injunction lifted 10/97• Repeal referendum defeated 11/97 (60% to 40%)• DEA threatens physicians 11/97• Reno reversal 4/98• Ashcroft re-reversal 11/01• TRO 11/01• PRO 4/02• 9th Circuit Court panel rules in favor of Oregon 6/04• Ashcroft appeals 9th Circuit Court panel decision 7/04• 9th Circuit Court “en banc” refuses request 9/04• Ashcroft appeals to US Supreme Court 11/04• US Supreme Court agrees to hear Gonzales vs Oregon 2/05• US Supreme Court oral arguments heard in 10/05• US Supreme Court rules in favor of Oregon 1/06• Senator Brownback introduces Assisted Suicide Prevention Act 8/06• Jack Kevorkian released from 8 years of prison 6/07
Utilization: 673 total—not thousands annually as predicted
2013 122 prescriptions 71 used medication
1998 to 2013 1,173 prescriptions 752 used medication
Prescriptions Deaths Alive at EOY
PAD deaths/10,000 deaths
Total 1,173 752 13.52013 122 71 21.92012 115 77 23.52011 114 71 22.52010 97 65 13 212009 95 59 12 192008 88 60 12 192007 85 49 13 162006 65 46 11 152005 64 38 17 122004 60 37 12 122003 68 42 10 142002 58 38 6 122001 44 21 11 72000 39 27 5 91999 33 27 2 91998 24 16 2 6
Prescription Recipients 1988-2013 (OHD)
16 Years ExperienceOregon’s DWDA•752 ingested medication•53% male•46% married•72% college educated•90% enrolled in hospice•98% had insurance• Median Age - 71
Oregon Department of Human Services March 2013
Oregon Department of Human Services March 2012
Home Long Term Care Hospital Other
Place of Death95% of Patients Died at Home
Underlying IllnessesDWDA DEATHS
2013 (n=71) 1998-2013
(n=752)
0
10
20
30
40
50
60
70
80
Malignant neoplasms (%)ALS or Lou Gehrig's diseaseChronic lower respiratory diseaseHeart diseaseHIV/AIDSOther
DEATHS WITHOUT DWDA
1998-2007 (n=98,942)
0
10
20
30
40
50
60
70
Malignant neo-plasms (%)ALS or Lou Gehrig's diseaseChronic lower respira-tory diseaseHeart diseaseHIV/AIDSOther
Patient Concerns(Reasons Expressed by those who used the law ODHS)
020406080
100
2013 (N=71) 1998-2013(N=748)
AutonomyAbility to enjoy lifeLoss of dignityControl of bodily functionsBurden on family, friends, caregiversInadequate pain control or concerns about itFinancial implications
HospitalistsLynn, Goldstein, Annals Int Med, 5/20/03
0
20
40
60
80
100
Per Cent
Sedation for Severe COPD/CLRD
Want sedation for self
Offer sedation to patient
When confronted with a request for PAD, health care providers should first work to bolster the patient’s sense of control and to educate and reassure the patient regarding management of future symptoms.
▪ Ganzini et al, “Oregonians’ Reasons for Requesting Physician Aid in Dying”, Arch Intern Med. 2009;169(5):489-492
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Future Concerns Motivate Requests
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
0
5
10
15
20
25
30
35
40
Referred for psychiatric evaluation
Two patients each in both 2012 and 2013 were referred for psychiatric/ psychological evaluation
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Psychiatric Evaluation (OHD)
Hospice Enrollment and Pain (OHD)
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 20130
10
20
30
40
50
60
70
80
90
100
HospicePainSeries3
Av = +90%
Hospice and ODDA (2007)
0102030405060708090
100
Hospice/PAD Hospice Declined
86% of Oregonians who died using Oregon’s Death with Dignity Act were hospice patients
Hospice and Hastened Death Hospice workers’ perspective important
▪ Visit patients and family caregivers often in last weeks of life
▪ Can compare hospice patients who request a prescription for lethal medication with other hospice patients
Hospice workers’ experience significant▪ Median length of stay for hospice patients in
1999 who used DWDA 7 weeks
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Hospice Nurses’ Experiences: Quality of Life (Rated on scales of 0-9) (Ganzini et al2002)
VariableVRFF (N=102)
(median time to death=15 days)
DWDA (N=55)
(waiting period=15 days )
P Value
Suffering (0=none) 3 2-5 4 2-7 0.007
Pain (0=none) 2 1-4 3 2-4 0.13
Peacefulness (0=peace) 2 1-5 5 1-7 0.04
Quality of death (0=bad death)
8 7-9 8 6-9 0.9526
An explanation for “very low rate of assisted” death may be the high quality of care provided by Oregon’s hospices.
▪ Ganzini et al, “Experiences of Oregon nurses and social workers who requested assistance with suicide”, NEJM 8/22/02
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Hospices Step Up to Plate
Resources
http://www.ann-jackson.com http://public.health.oregon.gov/Provi
derPartnerResources/Evaluationresearch/deathwithdignityact/Pages/index.aspx
http://www.oregonhospice.org http://www.ohsu.edu/ethics http://www.polst.org http://
www.compassionandchoices.org http://deathwithdignity.org
References and Resources Jackson A. Unreconcilable Differences? Are physician-aided death and hospice
philosophically at odds? Hastings Center Report, 41, no. 4: 4-9, July-August 2011.
Jackson A. Death with Dignity: Facts of Oregon's experience (Guest Opinion), Billings Gazette, July 17, 2010, online at http://billingsgazette.com/news/opinion/guest/article_e58042c0-9147-11df-843f-001cc4c03286.html; Montana Standard, July 29, 2010, online at http://www.mtstandard.com/news/opinion/columnists/article_40f87e52-9a98-11df-8409-001cc4c002e0.html.
Ganzini L, Goy E, Dobscha S, Prigerson H, Mental health outcomes of family members who request physician aid in dying, J Pain Symptom Mgmt, 2009
Hedberg K, Tolle S, Putting Oregon’s Death With Dignity Act in perspective: Characteristics of decedents who did not participate, J Clin Ethics, Volume 20, Number 2, Summer 2009 (133-135)
Hedberg K, Hopkins D, Leman R, Kohn M, The 10-year experience of Oregon’s Death With Dignity Act: 1998-2007, J Clin Ethics, Volume 20, Number 2, Summer 2009 (124-132)
Ganzini L, Goy E, Dobscha S, Oregonians’ Reasons for Requesting Physician Aid in Dying, Arch Intern Med. 2009;169(5):489-492.
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References and Resources (cont)
Dunn P, Reagan B, editors, The Oregon Death With Dignity Act: A Guidebook for Health Care Professionals, first edition 1998; current edition 2009 at www.ohsu.edu/ethics/guidebook.pdf
Hickman S, Nelson CA, Moss A, Hammes B, Terwilliger A, Jackson A, Tolle S. Use of the POLST (Physician Orders for Life-Sustaining Treatment) Paradigm Program in the Hospice Setting, J Palliat Med, Volume 12, Number 2, 2009
Jackson A. The Inevitable—Death: Oregon’s End-of-Life Choices. Willamette Law Review, Willamette University College of Law. Salem, Oregon, 45:1(137-160) Fall 2008.
Ganzini L, et al, Prevalence of Depression and Anxiety in Patients Requesting Physicians’ Aid in Dying: Cross Sectional Survey, 337 Brit. Med. J. 973, 975 (2008).
Miller P, Jackson A, Bae J, Communication at the End-of-Life: Social Work, Hospice and Oregon’s Death With Dignity Act, Or. Hospice Ass’n Professional Practices Exchange, Redmond, Oregon, Oct. 3, 2008, forthcoming www.oregonhospice.org/handout_downloads
Goy E, Carlson B, Simopoulos N, Jackson A, Ganzini L. Determinants of Oregon Hospice Chaplains’ Views on Physician-Assisted Suicide. J Pall Care, 22:2/2006; 83-90
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References and Resources (cont) Harvath T, Miller L, Smith K, Clark L, Jackson A, Ganzini L. Dilemmas
encountered by hospice workers when patients wish to hasten death. J Hospice & Pall Nursing, 2006;8(4):200-209
Simopoulos N, Carlson B, Jackson A, Goy E, Ganzini L. Oregon Hospice Chaplains’ Experiences with Patients Requesting Physician-Assisted Suicide. Pall Med 2005
Tolle S, Tilden V, Drach L, Fromme E, Perrin N, Hedberg K. Characteristics and Proportion of dying Oregonians Who Personally Consider Physician-Assisted Suicide. J Clin Ethics, Vol. 15, No. 2, Summer 2004
Ganzini, L., Goy, E., Miller, L., Harvath, T., Jackson, A., Delorit, M. Nurses’ experiences with hospice patients who refuse food and fluids to hasten death. NEJM, Vol. 349, No.4, July 24, 2003
Ganzini, L., Harvath, T., Jackson, A., Goy, E., Miller, L., Delorit, M. Experiences of Oregon nurses and social workers with hospice patients who requested assistance with suicide. NEJM, Vol. 347, No.8, August 22, 2002
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