Digging Deeper

Happy New Year! Hopefully you had a joyous holiday season, and may 2011 bring you and your loved ones health, happiness, and lots of success.

As you read this issue of Annals of Long-Term Care: Clinical Care and Aging (ALTC), you will find a Review, Case Report, and Perspective, each of which discuss different topics in long-term care yet share a common thread, with each article illustrating the importance of “digging deeper.” While healthcare professionals are already accustomed to doing investigative work, sometimes time constraints, various concerns, or assumptions may prevent us from extending our investigations beyond our comfort zones. In other cases, we may think that certain efforts are out of our jurisdiction or we may fear “rocking the boat.”

In the article “Preparatory Grief in Frail Elderly Individuals,” Meredith A. MacKenzie, MSN, RN, discusses the importance of evaluating frail elderly patients at the end of life for “preparatory grief,” a natural and normal process, and depression, which is abnormal and can severely decrease a person’s quality of life and hamper the grieving process. A point that MacKenzie emphasizes is the importance of engaging frail elderly patients who are facing the end of life in discussions about death. She notes that while many healthcare providers fear broaching the topic because they do not want to upset their patients, such discussions are often welcomed and can bring patients comfort. These discussions also enable healthcare providers to dig deeper into their patients’ psyches to determine whether they are grieving over their eventual death or are suffering from depression. Before healthcare providers embark on such discussions, MacKenzie notes that they should reflect on their own feelings of death, as this process would allow them to be more emotionally available to patients.

Sometimes patients present with disturbing and sudden symptoms. In “Levofloxacin-Induced Acute Psychosis in an Elderly Man,” Arnaldo Pires, MD, and colleagues, discuss the case of an elderly man who returned to their institution after exhibiting bizarre behavior and incoherent speech. Considerable investigative work was conducted to determine the cause of the man’s psychosis, including laboratory studies, computed tomography scanning, and an electrocardiogram, but it wasn’t until after he was admitted to the intensive care unit, where levofloxacin was discontinued, that the cause of his psychosis became clear. After stopping the levofloxacin, his symptoms quickly resolved. When digging through the literature, the authors found one similar case. Based on their experience, Pires and colleagues note that when clinicians are confronted with such cases, they need to consider the potential adverse effects of all medications that their patients are on. This may entail digging more deeply through a patient’s medical records, the literature, as well as the prescribing information of whatever medications a patient is taking.

In this issue, you will also find “The Medicare Hospice Benefit: A Changing Philosophy of Care?” by Charles A. Cefalu, MD, and Marco Ruiz, MD. This article, which will likely be considered by some to be more controversial than the article on hospice that appeared in our December issue (https://bit.ly/Hospice-ALTC-December), details the historical beginnings of hospice and outlines how hospice care has increasingly become business-driven. Cefalu and Ruiz note that certain legislation along with this more business-centric model has helped open the door to potential fraud and abuse in the hospice setting. They provide readers with several questionable scenarios that may constitute fraud and abuse or would likely be perceived by outsiders as fraud and abuse (eg, a hospice patient with full code status as per an advance directive), and they outline steps that should be taken when such situations are encountered. In some cases, after digging a bit deeper clinicians may bring clarity and help patients, their families, and institutions to rectify these situations.

We are pleased to announce that we have launched our redesigned Website this month, which is still accessible at www.annalsoflongtermcare.com. We trust it will now be easier for you to find and access the content you are looking for. Stop by and check it out, and be sure to vote in our poll while you are there.

If you are interested in submitting an article to ALTC, please view our author guidelines at www.annalsoflongtermcare.com. We are always interested in receiving your submissions.

We hope you enjoy the articles in this month’s issue. Thank you for reading!