2. Noción de trasfondo
2.1. El trasfondo medieval
Approximately 20 acute care hospitals in the state indicate that they have palliative care programs, including the Manchester Veterans Administration Medical Center (MVAMC). In particular, the
Dartmouth-Hitchcock Medical Center (DHMC) has long been a leader in New Hampshire and across the country in palliative care, especially its intersection with end of life care. Dr. Ira Byock, formerly with DHMC, is a leading authority on palliative medicine and was a significant influence in establishing DHMC’s Palliative Care Program. The program includes “A New
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Perspective on Living”, which includes a care team that coordinates the medical, social, and spiritual needs of the individual and family. They also run the “No One Alone”, Palliative Care Volunteer Program which utilizes volunteers to visit, write notes, read, or simply sit bedside to support the individual and family
(35).
New Hampshire, as a result of the work of advocates, has a very good state-wide policy for advanced care planning. However, New Hampshire law identified that only the official state document, as outlined in state statute, is a valid advance directive (Malley, 2012). This state statute could be a limiting factor in widespread adoption of AD’s. In January, 2015, the surrogate decision maker law (RSA 137-J) was enacted expanding the utility of AD’s. This law amends the state’s advance directive statute and establishes a hierarchy of family members/friends who may make health care decisions for patients in certain situations in the absence of guardianship or ADs.
In 2013, a survey of acute care hospitals in New Hampshire found that 51% of patients had an AD; however, in 2015, that number decreased to 49%. Survey data also showed that, in 2013, 35% of patients had an AD in their medical chart while, in
2015, only 37% had an AD. This data is significant in that the majority of older adults die in a health care setting, and one-third of older adults lack health care decision making capacity before they die. These factors highlight the importance of the use of ADs (S. LaFrance, personal communication, July 6, 2015).
Project ENABLE (Educate, Nurture, Advise Before Life Ends) is located in three New Hampshire communities (Lebanon, Manchester, and Berlin) and is a collaborative project with Norris Cotton Cancer Center at the DHMC to improve end of life care for cancer patients. ENABLE coordinates care between the cancer center and local health care providers and hospice programs. ENABLE hosts palliative care teams that include a pain management specialist, psychologist, hospice liaison, case manager, pastoral caregiver, and palliative care coordinator. They also offer educational seminars for families and patients to help in navigating end of life issues (36).
Provider Orders for Life Sustaining Treatment (POLST) is a system for portable medical orders for patients whose doctor or nurse practitioner think might die within the next twelve months. It is a voluntary program for patients and providers. A key objective is to improve the understanding and communication of a patient’s medical care choices
Quality Physical And Mental Well-Being Supports Are In Place
when patients move among different care settings (e.g., nursing home to hospital, hospital to hospice, etc.). The Foundation for Healthy Communities is a resource for education on POLST and offers a POLST Facilitator Education Program throughout New
Hampshire to train health providers as certified POLST
facilitators in their organization and community (37).
The New Hampshire Hospice and Palliative Care Organization is a state-wide organization educating healthcare professionals and other caregivers, increasing public awareness, and advocating for legislative and regulatory changes
(38). They sponsor an annual conference and website
that offers resources spanning many palliative care and hospice issues including advanced care planning, ‘having the conversation’, and POLST.
Best Practices Nationally
Access to Preventive Services
There are a number of evidence-based prevention programs that are being implemented for older adults throughout the U.S. One example is the Sickness Prevention Achieved through Regional Collaboration (SPARC). It was piloted in Atlanta, GA, and has increased the use of clinical preventive
services among older adults by increasing access points for their delivery and reducing logistical barriers. SPARC helps create partnerships between community organizations and health care providers to facilitate easy access to preventive services in one convenient place. For example, their initiative Vote & Vax, makes vaccines and appointments for cancer screenings available at polling places on election days (CDC, 2012).
Another prevention program, funded through the National Institutes of Health, is a fall prevention program specifically for older adults with visual impairments called “Osteopathic Medicine’s Balancing Act Program.” The program was developed in collaboration with the University of Maine’s Center on Aging, University of New England, and the Iris Network. It focuses on reducing falls through increasing balance abilities. The program requires only one training session from a trained facilitator and can be practiced by older adults at home with no equipment. The program also informs community programs about providing the best fall prevention information to older adults (Kahl, 2013).
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