Pallimed: A Hospice & Palliative Medicine Blog: Symptoms, Suffering, Parents and Pediatric Palliative Care in End-Stage Cancer, Part 2

A couple of weeks ago I posted on the Archives of Pediatrics and Adolescent Medicine article “Considerations About Hastening Death Among Parents of Children Who Die of Cancer." That study and the study I’m writing about here are retrospective cross-sectional surveys of parents whose children died of cancer at least one year previously. Joanne Wolfe, MD, MPH of the Dana Farber Cancer Institute, Boston was on both research teams.

This study, "Symptoms and suffering at the end of life in children with cancer: an Australian perspective" was published in the Medical Journal of Australia in mid-January. The abstract is here.

In the study’s introduction, it was pointed out that previous international studies may not apply to the Australian milieu since compared to many other developed countries there are system limitations in access to experimental cancer treatments and fewer pediatric oncologists available, also Australia's population is dispersed over huge physical distances, which leads to the development of local and regional treatment centers.

Here are some data highlights:

• Offered out-of-hospital palliative care: 82%, 75% opted in. Satisfaction rating of very good or excellent for out-of-hospital palliative care: 74%
• 47% received cancer-directed therapy in the last month of life, with 33% experiencing significant side effects. The perceived goal of cancer-directed therapy was 33% palliation, 12% extending life, 12% ensuring everything had been done. Children who received cancer-directed therapy during the end-of-life period suffered from a greater number of symptoms than those who did not receive treatment (p = 0.03).
• 63% had time to plan death location, of these 89% preferred to have the child die at home, and of these all except two died in the planned location; 61% died at home. Of those children who died in-hospital, almost 25% died in an ICU. Life-sustaining treatments were pursued in only 8%.
• Descriptive statistics were presented about symptoms, suffering, treatment and treatment success. It was notable that there was a significant gap between symptom treatment and treatment success. Despite this, 83% reported the death of their child was somewhat or very peaceful.

In conclusion, the authors noted “relatively high rates of death at home and low rates of heroic medical interventions suggest a realistic approach to care of children with cancer at end of life. However, many Australian children who die of cancer suffer from unresolved symptoms. Greater care should be paid to palliative care for these children.”

Some thoughts

"Making the decision to have a child is momentous. It is to decide forever to have your heart go walking around outside your body." ~ Elizabeth Stone

I think that taken together these two studies highlight the problems of under-treatment and late-treatment of symptoms in children with end-stage cancer, as well as importance of appropriate, anticipatory information for and communication with parents and caregivers. What caught my eye about these studies is that they were conducted and published at all, and upon further consideration, that they made it through the IRB process (having sat on one). I think that illness, suffering and death of children are psychologically white-hot. They touch upon our hopes, fears, guilt and shame, as health care professionals, and even more personally as family members ourselves, and as human beings.

I for one experienced the post-natal death of a sibling when I was seven-year-old; I rotated in the PICU, and routinely worked in a busy, urban children’s hospital emergency department; my young-adult son is training in the Army National Guard at this writing. The death of children, its memory, and the threat of death can loom very large indeed.

One appealing fantasy that may be afoot, which I know I can entertain, is that if we were just having EOL discussions earlier, and better prognoses where being made, and change of goals were initiated sooner, and these hospice -appropriate patients were enrolled in hospice earlier, then these kids and their families would suffer less. Certainly not very parsimonious, these are a lot of complex conditions. Even if we were able to smooth this terrible path some, and see greater and earlier enrollments into hospice, there is still the dying, the dying child and the child dying from cancer.

The expectation that we would be able to attain ideal symptom control if we were just given a fair shot, in a process as chaotic, dynamic and malignant as end-stage, pediatric cancer, is I think a fantasy. Alternatively there is doing one’s best by a patient, attending to the symptoms and the suffering in a context that is congruent and meaningful that is perhaps healing and even protective, especially for surviving parents, siblings, and other caregivers.

The Australian situation is different from other parts of the developed world as noted above. Perhaps an analogy might be drawn to the health care situation in rural and remote portions of the United States, where there are logistical barriers and cultural differences, and so the experience, meaning and memory may be different. That being said, even in the face of a yawning gap between symptom treatment and symptom treatment success, these parents were largely satisfied with the palliative care they received, and recalled the death of their child as being somewhat or very peaceful.

I think that there is a strong place for information, appropriate expectations, empowerment, good will, attention, professionalism and narrative to make a crucial difference in the experience of suffering, dying and grief, even, or especially in the case of children. That imperfect work is ours.

Heath JA, Clarke NE, Donath SM, McCarthy M, Anderson VA, & Wolfe J (2010). Symptoms and suffering at the end of life in children with cancer: an Australian perspective. The Medical journal of Australia, 192 (2), 71-5 PMID: 20078405

via pallimed.org

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Richmond County Daily Journal - Seminar drives home importance of hospice

Check out this website I found at yourdailyjournal.com

Richmond County Hospice Medical Social Worker Julieann Todd left those who attended the seminar on cancer and hospice care Wednesday with a message of encouragement about a discouraging subject. “Through education and communication, we can provide quality end-of-life care for our loved ones and our community,” Todd said. The two-part teleconference and panel forum was held at Cole Auditorium and was sponsored by hospice agencies in Richmond and Anson counties. “This is to educate the community, and not have late admissions,” Todd explained after the panel disbanded. “It’s really important that they come early so they can build a rapport with the hospice workers, so they’ll have the support that they need.” The first segment of the seminar was a Webcast of the Hospice Foundation of America’s 17th Annual Teleconference. Then the panel, a mix of area physicians and academics in the field, took questions from the audience and shared their own views about hospice care. The teleconference was designed to help participants understand the complexities of professionals working with end-stage cancer patients and their families when making the transition to hospice care. Then, participants were taught to assess how family members and other caregivers are coping with their grief, and acknowledge that decisions made and things that happen during the cancer illness and dying process can change the course of their grief. “We were thrilled with the turnout,” said Richmond County Hospice Volunteer Coordinator and Development Lisa Ledford. “We had about 150 people with us here today.” Ledford listed off some of the local panel members, which included Dr. Kelvin Raybon of Scotland Cancer Treatment Center, primary care Dr. Dierdre Young-Cadore of Hamlet and Hospice Chaplain and Bereavement Coordinator Colin Shaw. “There was a lot of information about cancer care, end-of-life treatment and hospice in general, which is so important,” Ledford continued. “With everything that’s going on in the world today, people need to understand that hospice is not a death sentence. It’s not meaning that it’s the end-of-life, but it’s all about the quality of life for what time we have left. That’s what we want to provide.” Richmond County Hospice has been doing that for 25 years by linking together diverse services like social work, nursing care, chaplain service and volunteers to come in and help families through their ordeal, Ledford explained. “There is just a whole wealth of services that are offered and that we can help people with through hospice care at the end of life,” Ledford said. Hospice volunteer Lynne Clewis said her family had received hospice care in Richmond County a decade ago, but there was a still a wealth of new information at the conference. “I just learned so much more about the transition, and so much more about what hospice offers and how it is such a big help to the families,” she said. Richmond County Hospice Volunteer Coordinator Faith Jones explained that she wanted those in attendance to take away the fact that they don’t have to do this alone. “It’s so important that when they are headed to hospice, they have a companion for emotional support and someone the family can trust with their loved one while still taking time for themselves,” Jones said. “That’s what we offer to our patients and their families through our volunteers.” Mary Heavner attended the conference, and had her own interpretation of what the underlying message was. “The public needs to be educated about hospice,” she said. “They have to know what services are offered, and hospice has a place where someone can explain all of those things to you.” More information is available about just how Richmond County Hospice eases the suffering of those who are terminally ill and those who stand by their side on its Web site, www.richmondcountyhospice.com. Staff Writer Philip D. Brown can be reached at (910) 997-3111 ext. 32, or by e-mail at pbrown@yourdailyjournal.com.

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This will offend some - and for that I am sorry....

Today was a very frustrating day.  Doctors were actually the highlight of my day.  The meetings I had with physicians took very positive forms with valuable communication. 

The frustration is in the community. 

I focus the majority of my efforts on community education about hospice but every now and then a family surprises me.  I know that for those on aggressive chemo the fight will last until the end even when, and sometime especially when, the chemo is palliative and not curative.  Why?  Has someone not communicated the quality of life expectancy along with the life expectency time frame?

I know a family whose oncologist suggested to our agency that we be on standby in case his patient decided to enroll in hospice.  We stood by.  We waited. Today I got the word that the prospective patient has 2 days to 2 weeks to live and the family doesn't want hospice because that stands for death.

???????? And 2 days to 2 weeks doesn't mean that?

I don't presume to think we can do exceptional work in such a short time frame but maybe pain and symptoms could be controlled in the hours that the medical world is sleeping with the exception of the ER or maybe we could relieve family members as we guide them through the progression of the transition.  Maybe.

Frustration really never serves me very well.  I will have to just let it go and try to communicate better with the people in my community who may be in need of hospice services in the future.

My prayer tonight is that suffering is minimal for this patient and their family. My resolve is strenthened to reach out and educate others about this wonderful service called hospice.

 

 

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HOSPICE: A Volunteer's Perspective - National Hospice Foundation

By Mary Anne Ramer, copyright 2009

Four years ago, I was a New York City-based writer and former journalist, newly semi-retired and looking for new ways to serve and give back to my community for all that I had received in my life.

I spent over nine months investigating a range of volunteer possibilities and finally chose hospice. I chose Continuum Hospice Care and was impressed with their initial and ongoing training. I can most easily and efficiently serve their clients in my area of Manhattan. They also offer volunteers a wide range of roles to fit both their patients’ needs and the changing circumstances of volunteers’ lives.

In the past three years, I have had three hospice patients as my clients (my term for the people I see weekly, since I have no medical, nursing or social work degree). Their ages range from 89 to 101. Two have heart conditions and one has cancer. Although none have Alzheimer’s or dementia, all have macular degeneration and the weakness that comes both with their illness and their age.

Whenever I choose to reveal to any friend or acquaintance that I am a hospice volunteer, I’m met with a range of responses, most of which are dead wrong or at best ill-informed.

I’d like to present, and refute, what I consider the seven most pernicious myths about hospice.

1.) “To volunteer with the dying, that is SO SAD! How can you stand it!”

While sadness is always a factor in many things in life, it is no more a factor in hospice than in many other things. In fact, I tell people that my little selfish secret is that I volunteer to rehearse for my own end of life!  Also, there is great care, love and even humor in serving my clients. You are never more your self, your true self, than when you at the last. The joy of a 100^th Birthday celebration with over 60 guests is something I will always cherish.

2.) “You mean you’re there when someone who’s not even a relative or friend is dying?”

If I were to train as a death doula, I may well be at a person’s actual death. However, in nearly all cases, hospice volunteers are not present at the time of their client’s death, unless they have specifically asked the person and the family if they may attend the dying. I would consider it an honor, not an ordeal.

3.) “Why do these people need volunteers?”

Although hospice care inherently includes a team (which is made up of doctors, nurses, social workers, health aides, spiritual support providers, and other skilled professionals) , it is the only Medicare/Medicaid funded service that REQUIRES volunteer service be provided. From the patient’s and family’s viewpoint, a volunteer is a non-paid, non-professional who has no legal, financial or even moral obligation to attend to a dying person. So volunteering is a true gift, as much as donating blood. And let’s be clear that the patient nearly always, and the family usually, become very aware of and grateful for that gift.

4.) “To be a volunteer, you have to go to a hospital. I don’t like hospitals.”

A small percentage of hospice patients are in a hospital for any time. The vast majority are cared for in their own homes, and a much smaller percentage in nursing homes. And I can say that visiting with a hospice patient in his or her home is a wonderful way to get to know them well, and to assist them in continuing, as much as they are able, to do those things that have given them joy all their lives – music, art, movies, reading, even games.

5.) “Isn’t hospice only for terminal cancer patients? I’m scared of cancer!”

In fact, hospice is for people with any medical condition that two physicians have certified will probably lead to their death within six months.

6.) “If these patients are so sick, isn’t it dangerous to be a volunteer to them?”

That is where good hospice training is a must. I learned how to handle any kind of possibility of contamination to me. Even more important, I learned how to prevent my contaminating the patient, which is much more likely. In fact, a very small percentage of hospice patients pose any threat to volunteers or anyone else.

7.) “I can’t put up with fact that asking for hospice services is giving up on your life.”

My message to anyone thinking about volunteering for hospice, or, even more, anyone who has a loved one who could benefit from hospice is: HOSPICE IS THE FINAL GIFT OF LOVE YOU CAN GIVE. You can give it to your loved one, and also to yourself. Why is that so? Because a well-run hospice program will provide the entire range of medical, social, and even psychological/emotional supports needed by the patient in one place. No more coping with up to a dozen different provider organizations, no more running around to office after office, no more one group not knowing what the other group is doing. The integrated care team concept of hospice is one of the best assets any patient and family can wish for.

I hope I have changed just one person’s mind about volunteering for hospice. Or changed the mind of one patient or one family about getting hospice on their side.

As for me, I look forward to continuing my hospice service, and helping many more people cross that finish line well.

Mary Anne Ramer is a New York City based writer who has served as a hospice volunteer since 2006. Since this article was completed, Ms. Ramer’s 101-year-old client crossed her finish line.

Note from NHF:  Your local hospice would be happy to tell you about their volunteering opportunities. Click here to find a hospice near you.

via nationalhospicefoundation.org

Become a hospice volunteer to grow your spirit of service. http://volunteertrainingonline.com

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14 states sue to block health care law

via cnn.com

Officials from 14 states have gone to court to block the historic overhaul of the U.S. health care system that President Obama signed into law Tuesday, arguing the law's requirement that individuals buy health insurance violates the Constitution.

Will other states join? How do you feel about being forced to buy a health care policy or be penalized?

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Hospice volunteer coordinator Sue Settje finds people with talent

Hospice volunteer coordinator Sue Settje finds people with talent

Sue Settje is the volunteer garden coodinator at Hospice

Dean Humphrey

Sue Settje is the volunteer garden coodinator at Hospice

Sue Settje is also in charge of buying the merchandise gifts available at Hospice.

Dean Humphrey

Sue Settje is also in charge of buying the merchandise gifts available at Hospice.

QUICKREAD

CHECK OUT THE PORTRAIT @ PLAY PHOTO GALLERY.

By Amy Hamilton
Monday, March 22, 2010

Strings of colorful baubles, sophisticated purses and vases in voluptuous shapes grace one shelf at the Miller Homestead’s Cups Coffee House.

The items are impossible for most women to miss and, sure enough, on a recent morning one woman halfway through a cup of coffee was drawn to the display to inspect a necklace laden with black and white trinkets.

“Only $22,” the woman exclaimed, fingering the price tag.

Sue Settje, who is responsible for bringing the treasures to the coffeehouse to sell, often hears that sort of thing. Settje, a volunteer coordinator for Hospice & Palliative Care of Western Colorado, is responsible for integrating much of the sensory experiences that go into the healing experience that hospice provides.

“I’m not the talent,” Settje is quick to point out. “My talent is being able to find people with talent.”

Four acres of thoughtfully fashioned gardens on hospice’s grounds are testament that Settje has found and nurtured that talent.

Of hospice’s more than 1,200 volunteers, 80 of those folks work to incorporate flowering greenery year-round through the organization’s Tanglewood Society. Those volunteers logged in more than 2,000 hours last year though gardening, creating floral arrangements in the Hospice Care Center, and maintaining merchandise displays.

Coming back to work for hospice is a natural fit for Settje. She has been both a staff member and a volunteer for the nonprofit for 16 years, stationed in her latest role for about the past three years.

Years ago Settje remembers when hospice would serve 50 patients a year. That has grown to 400 patients a year. Hospice was started locally in 1993 as a compassionate way to offer care to those with serious illnesses in the end of life stages and to offer support to loved ones.

“We know that every life we touch has a more graceful way of leaving this world,” Settje said. “We not only touch the patient’s life, we touch the loved ones’ lives as well, with grief counseling to get them through a difficult time.”

Settje is proud of the lovely and calming gardens that Tanglewood volunteers have created. All of the plants were donated, and each garden and feature is sponsored by area businesses.

Many of the gardens are in their second and third years and starting to fill out. The area, which is enclosed by a half-mile walking path and dotted with artful benches and water features, is a draw for patients, their families and staff.

“There is a lot of research done that being in a serene setting surrounded by nature is therapeutic,” Settje said. “There are raised beds that if someone is in a wheelchair they can cut a fresh herb or they can touch and feel the flowers.”

Tanglewood volunteers have a knack for bringing the outdoors in by rearranging donated floral arrangements. Volunteers separate the larger bouquets into smaller more personal arrangements to spread joy at the care center.

Settje’s role is to ensure volunteers are placed into roles that fit their personalities. She still laughs thinking about a time when a woman really wanted to volunteer at hospice but, unknown to Settje, abhorred gardening. The woman lasted about half a day with her hands in the dirt, but after coming clean about her needs, found other work that fit her skills within the organization.

Hospice is always seeking volunteers and has a variety of chores that span a broad range of talents, Settje assured.

“It’s such a wonderful, beautiful place to work that I just can’t imagine anybody not wanting to work here,” she said.

via gjsentinel.com

What a story! This hospice really has emphasized the caring and compassion that evolves from hospice care. I enjoy seeing volunteers bring beauty and light to an otherwise darkened day.

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Hospice Volunteer Training Online

Check out this website I found at volunteertrainingonline.com

I love it when I choose to advertise and test the link and find it hasn't been working in several days. Challenges are what make me grow stronger - today I am Superman!

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Health Care Reform Bill Has Moved Through Congress – The National Hospice and Palliative Care Organization

Check out this website I found at capwiz.com

Health Care Reform Bill Has Moved Through Congress A Quick Recap For more than a year, the hospice community has been on the edge of our collective seat, watching the political process that has consumed health care reform. First there were three bills, and then the House and Senate each settled on one version they each wanted to put forth. At the end of 2009, we were waiting to see if and when the White House would weigh in and choose a direction to pursue toward passage. At the same time, Republican leadership continually urged for a re-start of the process, from scratch. Along the way, we lost Senator Ted Kennedy, a long time health reform champion and a very good friend of the hospice community. We've also had multiple changes in leadership of the committees with jurisdiction over health care reform. To say that this journey has been a winding road is an understatement, but with each curve, Hospice Advocates have been very clear and unified in our messaging to Congress. During this process, we have sent Purple Folder Letters to the White House by the dozen, filled up the White House Comment Line, and contacted Congress (more than 70,000 contacts) so much that they probably recognize you by name! Now this part of the process is drawing to a close. In the past 24 hours, Congress has moved into the final stages of this round of health care reform. What Passed and What it Means for End-of-Life Care Sunday night, by a vote of 219-212, the House passed H.R. 3590, the Patient Protection and Affordable Care Act. H.R. 3590 is actually the version of health reform that originated and passed out of the Senate last December. This version of the bill, the one that has now passed both chambers of Congress, softens the productivity cuts to hospice from a proposed $10 billion to $7.8 billion. Here's an overview of what is in the final package relevant to end-of life care: * Market Basket Cuts & Productivity - Incorporates a productivity adjustment reduction into the market basket update beginning in fiscal year 2013, as well as a market basket reduction of .3 percent for hospice providers from fiscal years 2013-2019. Note that these cuts will not take effect until FY 2013. * Hospice Payment Reforms - (1) This provision would require the Secretary to collect data and update Medicare hospice claims forms and cost reports by 2011. (2) Based on this information, the Secretary would be required "implement revisions to the methodology for determining the payment rates for routine home care and other services included in hospice care" no earlier than FY 2013. (3) After January 1, 2011, a hospice physician or nurse practitioner must have a face-to-face encounter with each hospice patient to determine continued eligibility for hospice care prior to the 180th-day recertification and each subsequent recertification, and attest that such visit took place. In addition, the Secretary will medically review certain patients in hospices with high percentages of long-stay patients. * Medicare Hospice Concurrent Care Demonstration Program - Directs the HHS Secretary to establish a three-year demonstration program that would allow patients who are eligible for hospice care to also receive all other Medicare covered services while receiving hospice care. The demonstration would be conducted in up to 15 hospice programs in both rural and urban areas and would undergo an independent evaluation of its impact on patient care, quality of life and spending in the Medicare program. * Curative and Palliative Care for Children in Medicaid and CHIP - Allows children who are enrolled in either Medicaid or CHIP to receive hospice services without foregoing curative treatment related to a terminal illness. * Independent Payment Advisory Board - Creates an independent Payment Advisory Board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries as well as the private health system. When Medicare costs are projected to be unsustainable, the Board's proposals will take effect unless Congress passes an alternative measure that achieves the same level of savings. Congress would be allowed to consider an alternative provision on a fast-track basis. Requires the Board to make non-binding Medicare recommendations to Congress in years in which Medicare growth is below the targeted growth rate. Beginning in 2020, requires the Board to make binding biennial recommendations to Congress if the growth in overall health spending exceeds growth in Medicare spending. * Hospice Value Based Purchasing/Promoting High Value Health Care - Provides the Secretary of HHS the authority to test value-based purchasing programs for long-term care providers, including hospice providers, no later than January 1, 2016. * Quality Reporting - Requires hospice to report on quality measures determined by the Secretary (endorsed by the new quality measure consensus-based entity) or face a 2 percent reduction in their market basket update. Measures published in 2012 for reporting to begin in 2014. * Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long-term care Facilities and Providers - Establishes a national program for long- term care facilities and providers to conduct screening and criminal and other background checks on prospective direct access patient employees. * Advancing Research and Treatment for Pain Care Management - Authorizes an Institute of Medicine Conference on Pain Care to evaluate the adequacy of pain assessment, treatment, and management; identify and address barriers to appropriate pain care; increase awareness; and report to Congress on findings and recommendations. Also authorizes the Pain Consortium at the National Institutes of Health to enhance and coordinate clinical research on pain causes and treatments. Establishes a grant program to improve health professionals' ability to assess and appropriately treat pain. * Education and training programs in pain care - Secretary may make grants available to hospices and others to develop and implement pain care education and training programs for health care professionals. You may still hear talk of the reconciliation bill over the next week or two. More information on that package and the related legislative process can be found in our previous health care reform update. However, we feel confident that all of the health reform provisions that will impact hospice are contained in the package that passed yesterday and are listed above. We're Still Fighting While we appreciate the fact Congress continues to embrace hospice as a vital part of health care at the end of life and we're pleased to see the provisions included expanding access to hospice, we simply can't afford to lose $7.8 billion from the national investment in end-of-life care. We have said it all along; two cuts are too much for hospice. And, we mean it. The productivity cuts on top of the more than 4 percent regulatory reduction associated with the elimination of the budget neutrality adjustment factor (BNAF) we are absorbing over the next seven years, is more than the community can or should sustain. As an aside, you, as a Hospice Advocate, working through NHPCO, were the reason the phase-in of the BNAF cuts went from the previous Administration's plan of three years, to the current schedule of seven years. This gives the hospice community more time to plan for and manage the implementation of these unwarranted cuts. Accordingly, with Capitol Hill Day 2009 just weeks away, NHPCO will be leading the hospice community in a measured, strategic, and phased fight to further soften the cuts before they go into effect in 2013. We've done what we needed to do for this phase of health reform. The hospice community was a resource to Congress during this trying past year. We were heard when we said $10 billion was too much to take from hospice and our policy makers heard us when we asked for increased access to hospice for pediatric patients and concurrent care. NHPCO will continue to ensure that hospice is "at the table" after the political dust settles and before the community and the patients we serve feel the brunt of the cuts. You may be asking, "Why wait until Hill Day, why does it need to be phased?" To be honest, the health care decision makers on Capitol Hill are going to be burned-out and not ready to revisit the reform legislation for a while...probably not until after the November elections. But, that's good news for us. With Hill Day, away from all the "noise" of health care reform, we will launch an education effort to reacquaint our federal elected officials with the Medicare Hospice Benefit, who we are as a community, the patients we serve and the invaluable services that are provided by hospice in every community across the nation. A focused and consistent re-education effort is critical to a successful, phased strategy to get additional relief from the cuts. Immediate Next Steps Obviously, the more people we can get on Capitol Hill on April 21st, the stronger the launch of our re-education effort will be. So, visit the Hill Day 2010 Information Page for more information and to register. And for those of you who cannot join us in D.C., stay tuned for exciting opportunities to participate from home! Most importantly, as a unified community with one voice, we need to get the facts together to show Congress what the cuts will mean to the hospice programs that serve their communities and constituents. The NHPCO Regulatory Team has been hard at work on a comprehensive, easy-to use calculator for programs to use to determine the long-term impact of the combined cuts. NHPCO members should receive an email in the coming days with a link to this interactive tool. As always, we thank you for your Hospice Advocacy. We may not have the end-result we want yet, but your efforts have come a long way in advocating for the patients and families who depend on compassionate, high-quality end-of-life care. Please let us know if you have questions about any of this information by contacting advocacy@nhpco.org.

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Landmark health care overhaul bill heads to Obama\'s desk

via cnn.com

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