VA Testimony of Thomas V. Holohan, MD before Congress on October 19, 1999

United States Department of Veterans Affairs

STATEMENT OF
THOMAS HOLOHAN, M.D.
CHIEF PATIENT CARE SERVICES OFFICER
AND
JUDITH A. SALERNO, M.D., CHIEF CONSULTANT
GERIATRICS AND EXTENDED CARE STRATEGIC HEALTHCARE GROUP
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
ON
IMPROVING CARE AT THE END OF LIFE
WITH COMPLEMENTARY MEDICINE
BEFORE THE
COMMITTEE ON GOVERNMENT REFORM
U. S. HOUSE OF REPRESENTATIVES

October 19, 1999

Mr. Chairman and members of the Committee, we are pleased to appear before you today to provide an overview of the Department of Veterans Affairs’ (VA) experience and initiatives in improving end-of-life care for its veteran patients.

VA has made a significant commitment to improving care at the end of life for our veteran patients. There are several factors that make it important for the VA to focus on this crucial issue at this time:

Serious, life-limiting illnesses are prevalent in the aging veteran population;
VA is the nation's largest integrated healthcare system;
VA has decades experience in geriatric and palliative care;
VA's academic and educational affiliations provide an opportunity to influence the education of large numbers of physicians, nurses and other health care professionals in the area of end-of-life care; and

VA's research capacity provides an opportunity to strengthen the knowledge base in end-of-life care.

VA has recognized that our resolve to confront these issues can offer leadership that will benefit not only veterans, but all Americans.

In 1997, VA initiated a national strategic effort to improve care at the end of life. A national summit was held in May 1998 for the purpose of developing a comprehensive, system-wide VA strategy for improving care of veterans at the end of life. The recommendations of the Institute of Medicine (IOM) Committee on Care at the End of Life published in the report, "Approaching Death: Improving Care at the End of Life" (1997) served as a framework for the strategy summit. It should be noted that VA is probably the only single health care system in the United States with the capacity to address each and every recommendation made by the IOM committee. The specific elements of VA's national strategy to improve care at the end of life include:

identification and dissemination of state-of-the-art practices in care of the dying;
improving systems and organizational processes to achieve reliable, excellent care for patients during the last phase of life;
strengthening methods for measuring processes and outcomes of care for dying patients and their families;
designing education for VA health professionals and affiliated trainees to assure that caregivers have the knowledge, skills and attitudes to care well for dying patients and their caregivers;
empowering patients and their families through education about care at the end of life;
collecting data on quality, access, cost and utilization to inform public policy; and
collaborating with other national organizations and with health care providers that are similarly committed to improving the care of patients during the last phase of life.

The summit brought together individuals from across the VA health care system who have demonstrated interest, expertise and leadership in this area, along with non-VA experts and national opinion leaders. Three strategic goals were identified:

No dying veteran shall suffer from preventable pain while being cared for by the VA health care system.
Every veteran with a serious, life-limiting illness receiving care from VA shall have an individualized plan for comprehensive, coordinated, palliative care services that minimizes physical, psychological, social and spiritual suffering and optimizes the patient's quality of life.
Every veteran enrolled in the VA health care system who has a serious, life-limiting illness shall have access to hospice care and/or palliative care services and shall have an understanding about the availability of those services.

During the past two years, VA has made tremendous strides in developing and implementing programs for improving care at the end of life, based on these simple, direct, but profoundly important tenets. Programs and projects have been developed at the local, regional and national level. A brief overview of some of VA's activities is outlined below.

1. Network Directors Performance Measure: Palliative Care Index

In 1997, the VA initiated a national performance measure to assure that patients with incurable, life-limiting illnesses have an individualized, comprehensive plan for coordinated palliative care services. To meet the intent of the measure, the plan must include: discussion of care alternatives and treatment settings with the patient and/or family; discussion of advance directives (a patient's specific written instructions regarding future health care decisions); effective palliative symptom management; psychological, social and spiritual support for the patient; and continuity of care coordinated over a continuum of health care settings. National performance has improved from 52% compliance in the third quarter of FY 1997 to 94% in the second quarter of FY 1999, reflecting the enthusiasm with which VA health care providers have undertaken to improve end-of-life care for veterans.

2. VA Faculty Leaders Project for Improved Care at the End of Life

The VA Faculty Leaders in End-of-Life Care project was initiated in 1998 with support from the Robert Wood Johnson Foundation. The project has identified faculty leaders at 30 internal medicine residency training programs affiliated with VA throughout the nation. The Faculty Leaders are participating in a two-year project designed to assist them in developing and implementing benchmark curricula for state-of-the-art care for patients through the end of life. The Faculty Leaders have shared their progress at several national conferences. A web site has been developed as part of this project and has become a valuable resource on end-of-life care for physicians and other health care professionals both within and outside VA. The web site for the VA Faculty Leaders Project is http://www.va.gov/oaa/flp.

3. Breakthrough Collaborative on Improving Care for Patients Approaching the End of Life with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF)

VA recently co-sponsored a quality improvement initiative with The Institute for Health Improvement (IHI) and the Center to Improve Care of the Dying (CICD) that focused on devising systems for better care for patients approaching the end of life with CHF and COPD - common serious conditions found in VA patients as well as in all older populations. Seventeen VA sites participated in the nine-month collaborative, and a number of them achieved breakthrough improvements in care. Some of the innovations that were implemented during the collaborative included: improved continuity of care across settings, successful patient and family education; advance care planning; improved symptom management; and improved patient and family self care. Several participating VA sites significantly reduced the episodes of symptom exacerbation, which resulted in fewer emergency room visits and hospitalizations. Results of the collaborative were presented at a national conference in Atlanta in September 1999, and several of the improvements will be featured at the VA National Leadership Conference on Pain Management and End of Life Care, which will be held November 2 - 5, 1999, in Crystal City, VA.

4. VA National Pain Management Strategy

As an outgrowth of the VA's efforts in end-of-life care and the substantial attention given to pain management issues by VA's Anesthesiology Service, VA has implemented a national strategy to develop a system-wide approach to reduce pain and suffering for veteran patients across all VA health care settings. An expert coordinating committee has been appointed to oversee the development and implementation of the national strategy. In March 1999, VA initiated a national policy to assess pain as the "5th vital sign." The goal of this initiative is to assure that pain assessment is performed in a consistent manner, and throughout the VA healthcare system. The overall objectives of the VA national strategy for pain management are to:

provide a system-wide VHA standard of care for pain management that will reduce suffering from preventable pain;
assure that pain assessment is performed in a consistent manner;
assure that pain treatment is prompt and appropriate;
include patients and families as active participants in pain management;
provide for continual monitoring and improvement in outcomes of pain treatment;
provide for an interdisciplinary, multi-modal approach to pain management; and
assure that clinicians practicing in the VA healthcare system are adequately prepared to assess and manage pain effectively.

The VA National Pain Management Strategy recognizes the need to take a long-term approach to improving pain management, and is committed to continual improvement in assessing and treating pain. The VA strategy also recognizes the importance of an interdisciplinary approach to pain management and the role of non-medical modalities for treating acute, chronic and cancer pain.

5. Alzheimer's CARED Project (Caregiver Assessment Regarding End-of-Life in Dementia):

In 1998, VA received support from the Alzheimer's Association for a year-long research project on end-of-life care for patients with Alzheimer's Disease. Through the CARED Project, based at the Bedford, Massachusetts VA Medical Center, VA is reviewing the current status of end-of-life care for patients with dementia and developing recommendations for an innovative home- and community-based service model. The Geriatric Research, Education and Clinical Center (GRECC) at Bedford, which is coordinating the CARED project, has accomplished cutting-edge research in care for patients with advanced dementia. Dr. Ladislav Volicer and Dr. Ann Hurley at the Bedford GRECC are nationally known as leaders in palliative care for patients with dementia. They co-authored the book "Hospice Care for Patients with Advanced Progressive Dementia" published in 1998. One of the significant outcomes of Dr. Volicer’s

and Dr. Hurley's work is a unique model for advance surrogate decision-making that involves interdisciplinary team/family conferences.

6. Hospice Care

VA is working to increase access to hospice care for veterans who need and want to receive hospice services. Currently the VA has 59 inpatient hospice programs in VA medical facilities. Nearly all VA medical centers have hospice consultation teams, and most VA medical centers work closely with community-based hospices to provide home hospice care to veterans. Hospice care is one of the services included in the uniform benefits package that is available to all veterans enrolled in the VA healthcare system. Currently, VA is exploring ways to use our sharing and contracting authority to increase access to hospice care for veterans. For example, a pilot project being implemented this month at the VA medical center in Palo Alto expands the VA inpatient hospice capacity to provide reimbursable inpatient hospice care to community hospices with the proceeds substantially supporting additional hospice beds for veterans. A number of other VA facilities have been exploring the feasibility of entering into use-of-space agreements with community hospices to operate inpatient hospice units in unused VA inpatient space. We are optimistic that these efforts will increase access to hospice care, which has already increased 21% since 1995.

7. Palliative Care

There are many terminally ill individuals who would not choose traditional hospice care. VA has a number of excellent palliative care programs, including one of the few Alzheimer's palliative care units in the nation, which is a major initiative of the Bedford GRECC. In addition to inpatient palliative care, a number of VA facilities provide excellent palliative care in the home through their Home-Based Primary Care (HBPC) programs. The VA HBPC program is very similar to hospice in that it provides an interdisciplinary, holistic approach to care and is specifically designed to serve long-term, seriously chronically ill patients. The advantage of the HBPC program is that, unlike the Medicare hospice benefit, the patient need not have a prognosis of six months or less to live. Many HBPC programs serve patients who are terminally ill with non-cancer diagnoses and for whom it would be difficult or impossible to predict whether they will live for six months. The unique advantage that the VA HBPC programs have over Medicare hospice is that they can offer a combined approach to care --good supportive care services along with excellent medical disease management. Patients are not forced to make an artificial choice between "palliative care" and "aggressive care," but rather can receive the care that is most appropriate for their individual needs. Several of the VA HBPC programs (Tampa, Tucson, Indianapolis) are piloting programs specifically designed for patients who are approaching the end of life with CHF and COPD. The interdisciplinary team approach to care in the home provides support for family caregivers. In addition, several HBPC programs are using community volunteers to provide additional caregiver support.

8. VA National Leadership Conference in Pain Management and End-of-Life Care

This national conference, scheduled for November 2-5, 1999, will bring together 300 experts, innovators, change agents and direct care providers from across the VA health care system. The goals of the conference are to:

provide education on pain management and end-of-life care for health care providers of all disciplines and at all levels in the organization;
facilitate planning and problem-solving related to organizational systems;
feature state-of-the-art practices and innovations throughout the VA; and
provide an opportunity for networking and collaboration and sharing of ideas.

Response to the call for participation for the conference has been enthusiastic across VA, with many impressive projects and programs from individual VA medical centers and networks being brought to the forefront. The conference is designed to be interdisciplinary and holistic, reflecting attention to the medical, social, and spiritual needs of patients. Spiritual and emotional support for patients, as well as non-medical modalities of care, will be the focus of several of the breakout sessions because we recognize the central role they play in planning for the needs of dying patients.

9. Supportive Services and Complimentary Therapies

VA national policy supports and encourages comprehensive management of the physical, psychological, social, spiritual and existential needs of patients with advanced, incurable illness. Palliative care affirms life and regards dying as a natural process that is profoundly personal for the individual and family. The goal of palliative care is to achieve the best possible quality of life through relief of suffering, control of symptoms, and restoration of functional capacity while remaining sensitive to personal, cultural, and religious values, beliefs and practices. VA has taken the position that any treatments that are supported by good evidence of safety and effectiveness should be available to our patients, consonant with their risks and benefits as compared with other interventions. Complementary therapies that are available at some VA medical centers include relaxation, visualization, music therapy, art therapy, healing touch, aroma therapy, massage, Tai Chi Chuan (a Chinese exercise therapy), and reminiscence (life review) therapy. Spiritual care is available to patients at VA facilities through VA’s active Chaplaincy Service. Chaplains of all faiths function as key members of the interdisciplinary VA team. Bereavement support for families and memorial services are part of many of VA's hospice and palliative care programs. VA also supports and encourages attention to multi-cultural approaches to healing. For example, a number of VA medical centers that serve Native American veterans have made available sweat lodges and Native American healers who desire those services.

The power of arts is an important part of the palliative care supporting patients at the VA Nursing Home Care Unit in Washington, D.C. Patients are introduced to all of the creative arts through a program that provides a means of expression and helps veterans to reflect upon their lives. There is a literary arts as well as visual and performing arts component in which family members can participate. A poetry program has been very popular with nursing home patients, some of whom have been escorted to recite at poetry readings. An annual calendar created and published by and for the patients is a highlight of the unit’s activities. VA supports evidence-based complementary therapies in concert with conventional therapies as part of a commitment to excellent care for veterans during the last phases of life.

Summary

Over the past two years, VA has made tremendous and measurable strides in improving care at the end of life for our veteran patients. We realize that these efforts have not fully matured. Indeed, there will always be more for us to do and fresh ideas to test about how to better serve the needs of our dying and suffering patients. The extraordinary attention that VA has received for its end-of-life and pain management activities comes from the recognition that no other major health care system has set its sights so high. The opportunities for VA to lead by example and effect change in the culture of health care are enormous. We have accepted that challenge and remain steadfast in our goal to provide our dying patients with care that affirms life, recognizes the right to self-determined life closure and achieves the best possible quality of life through relief of suffering and compassionate care.

Thank you, Mr. Chairman, for the opportunity to provide the Committee with information about VA's initiatives on end-of-life care. We will now be happy to answer any questions that you or other members of the Committee might have.