Treatment of CHO-K1 cells with 25-hydroxycholesterol produces a more rapid loss of 3-hydroxy-3-methylglutaryl-coenzyme A reductase activity than can be accounted for by enzyme turnover.

A key enzyme in the regulation of mammalian cellular cholesterol biosynthesis is 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMG-CoA reductase). It is well established that treatment with the compound 25-hydroxycholesterol lowers HMG-CoA reductase activity in cultured Chinese hamster ovary (CHO-K1) cells. After brief incubation (0-4 h) with 25-hydroxycholesterol (0.5 microgram/ml), cellular HMG-CoA reductase activity is decreased to 40% of its original level. This also occurs in the presence of exogenous mevinolin, a competitive inhibitor of HMG-CoA reductase which has previously been shown to inhibit its degradation. The inhibition of HMG-CoA reductase activity by 25-hydroxycholesterol is complete after 2 h. Radio-immune precipitation analysis of the native enzyme under these conditions shows a degradation half-life which is considerably longer than that of the observed inhibition. Studies with sodium fluoride, phosphatase 2A, bacterial alkaline phosphatase and calf alkaline phosphatase indicate that the observed loss of activity is not due to phosphorylation. These data are not consistent with described mechanisms of HMG-CoA reductase activity regulation by phosphorylation or degradation but are consistent with a novel mechanism that regulates the catalytic efficiency of this enzyme.

Symptoms and attitudes of 100 consecutive patients admitted to an acute hospice/palliative care unit.

One hundred patients admitted to an acute hospice/palliative care unit in a U.S. teaching hospital were evaluated using a standardized data acquisition tool that assessed the presence of physical symptoms and attitudes concerning admission to such a specialty unit. Patients entering the unit between June 1995 and October 1995 completed the tool within 24 hours of admission. Symptoms reported were fatigue in 81 patients, anorexia in 70, dyspnea in 61, xerostomia in 58, cough in 52, pain in 49, confusion in 37, depression in 37, constipation in 35, nausea in 30, insomnia in 23, and vomiting in 22. Of the 59 patients and family/friends that responded to the question "How do you feel about hospice care?", 53 gave a positive response. When asked about the best aspects of the unit, the most common response related to the care the patient and family received (23 responses, 39%). We conclude that patients admitted to an acute inpatient hospice/palliative care unit have multiple symptoms and a high degree of satisfaction with the environment.

Hospice and palliative care: program needs and academic issues.

With the renaissance of interest in how best to care for patients with terminal illness comes the need to recognize palliative care and hospice programs as the completion of comprehensive cancer care, not as its antithesis. In practical terms, admission to a hospice program is appropriate when efforts to control the biologic disease have ceased to be helpful and the primary medical focus is on symptom control and quality of life. In this article, the authors explore the goals of palliative care, review the transition to a hospice program, and assess the Medicare Hospice Benefit. Furthermore, they reflect on the importance of and barriers to the appropriate adoption of palliative care programs as well as palliative care education in oncology.

A program of hospice and palliative care in a private, nonprofit U.S. Teaching hospital.

A hospice and palliative care program was established at Northwestern Memorial Hospital, a 773-bed private nonprofit hospital located in the urban center of Chicago. The program consists of three components: consultation service, acute inpatient unit, and home-hospice program. The consultation service saw an average of 57 new patients per month (range 45-80) in fiscal year 1997. The 12-bed acute care inpatient unit had an average midnight census of 9.8 in fiscal 1996. This decreased to 6.9 in fiscal 1997 due to new treatment approaches for AIDS and has rebounded to nine in the third quarter of fiscal 1998. The unit cares for more than one third of dying patients in the hospital. Patients do not have to access hospice insurance benefits to be admitted to the unit. The home-hospice program has a median length of stay of 31 days and serves patients living within the city limits of Chicago. A total of 800 patients were referred to the program, and 370 patients died in the program in fiscal 1997. A total of 219 different physicians were attending physicians for patients in the program during a 3- year period. Revenue exceeded direct expenses by $1.48 million. Fee-for-service billing for physician services outside of those provided or billed under the Medicare Hospice Benefit are not included in these figures. The group practice that bills for the physicians collected an average of 50.5% of billed charges over 4 years. We conclude that a program of hospice and palliative care can be successful in a private teaching hospital in the United States.

Terminal care for noncancer patients.

The hospice approach to terminal care will benefit patients with advanced chronic illnesses other than cancer. This article describes general criteria that will help clinicians assess when patients may be appropriately referred for hospice care. Common illnesses, such as dementia, heart disease, lung disease, and renal failure for which terminal care in advanced stages is appropriate, are discussed. Specific palliative management issues regarding these advanced disease states also are addressed.

Antisecretory agents in gastrointestinal obstruction.

Gastrointestinal obstruction is associated with nausea, vomiting, and abdominal pain. Antisecretory agents can relieve these symptoms, even in the absence of surgical or mechanical intervention. These medical management approaches are outlined, and recommendations are made.

Abdominal cancer, nausea, and vomiting.

Nausea and vomiting in abdominal cancer is perhaps one of the most difficult symptom complexes to manage, especially when complicated by bowel obstruction. There are many mechanisms of nausea in advanced abdominal cancer with a number of therapeutic interventions that can significantly enhance symptom control and overall quality of life. As with pain, the ideal approach should include a mechanistic analysis of the causes of nausea beginning with a thorough history, followed by a directed physical examination, and selected laboratory studies. The symptom history, in conjunction with a physical examination and directed tests should direct appropriate pharmacologic and nonpharmacologic interventions. The result is often the amelioration of significant suffering and enhanced quality of living.

Physician board certification in hospice and palliative medicine.

The American Board of Hospice and Palliative Medicine (ABHPM) was formed in 1995 to establish and implement standards for certification of physicians practicing hospice and palliative medicine and, ultimately, accreditation of physician training in this discipline. The ABHPM has created a certification process that parallels other member boards of the American Board of Medical Specialties (ABMS). After 3(1/2) years and the administration of seven examinations, 623 physicians have achieved board certification in hospice and palliative medicine. Those with ABMS primary board certifications have been certified by anesthesiology, 4%; family practice, 23%; internal medicine, 55%; pediatrics, 1%; radiation oncology, 2%; and surgery, 2%. The majority describe their practice location as urban. Sixty-nine percent report more than 5 years of clinical experience in hospice/palliative medicine and 75% report an association with a hospice as medical director or hospice physician. Sixty-seven percent belong to the American Academy of Hospice and Palliative Medicine. Applicants were drawn from 48 states, Canada, and 3 foreign countries. The available data indicate only 20% were less than 40 years of age and that two-thirds were men. There is significant physician interest in seeking professional recognition of expertise in caring for terminally ill persons and their families through creation of a specialty in hospice and palliative medicine. Certification of physicians and accreditation of training programs are key elements in this process. This process will encourage more physicians to enter this field and provide needed expertise in the management of patients with progressive disease for whom the prognosis is limited, and the focus of care is quality of life.

Coding and reimbursement mechanisms for physician services in hospice and palliative care.

Many physicians misperceive that the current coding system used to bill third-party payers in the United States does not include codes related to hospice and palliative care. This article will help physicians and hospice and palliative care providers to: 1) understand how to code for physician services related to hospice and palliative care; 2) review the documentation required to support such services; 3) understand the differences between the reimbursement mechanisms to be used when the patient is enrolled in the Medicare Hospice Benefit, and the usual reimbursement mechanisms; and 4) understand some of the approaches for funding non-physician palliative care services for patients not enrolled in the Medicare Hospice Benefit.

Clinical experience in hospice and palliative medicine for clinicians in practice.

Many healthcare professionals already in practice have identified their need to pursue further practical training in the provision of hospice and palliative care. We began offering a 1-week clinical experience to physicians, nurses, pharmacists, social workers, and chaplains in the summer of 1995. As of October 1,1997, there have been 190 requests for application materials from individuals in more than 22 states, as well as from Singapore and Uganda. Thirty-five individuals completed visits by October 31,1997; 17 nurses, 16 physicians, 1 psychologist, and 1 chaplain. Although all are working in areas related to palliative care, 57% (20 of 35) were not currently working for a hospice program. A 25-question examination was administered as a needs-assessment test. Overall they scored 75% correct. They did especially poorly on questions related to dosing of opioids, assessment of pain, and prognosis in AIDS. They completed a videotaped interview with a standardized patient focusing on skills in discussing a terminal prognosis, "do not resuscitate" (DNR) status, and hospice referral. They evaluated the entire educational experience with a self-report at the end of their visit using a Likert Scale with values of 1 to 5. To the statement "I achieved the specific goals which I set for myself," the average score was 4.6 (range 1-5). To the statement "The experience was worth the time and effort," the average score was 4.9. To the statement "I would recommend this experience to others," the average score was 4.9. The evaluation was repeated 6 months after the visit with similar scores. In addition, to the statement "My current efforts are helping to change the way dying patients and their families are cared for in the broader environment in which I work," the average score was 4.9 (range 4-5). We conclude that this is a successful program of clinical exposure to hospice and palliative medicine for clinicians in practice.

Prospective evaluation of referrals to a hospice/palliative medicine consultation service.

A hospice/palliative medicine consultation team was formed in July 1993 in a U.S. teaching hospital to provide patient care and education. The team consists of an attending physician, nurse, fellow, and any residents or medical students rotating on the service. More than 500 consultations are received each year. Beginning in January 1995,108 consecutive referrals to the service were assessed using a standard form completed by the nurse. The average age was 62 years. The gender of patients was 58% male and 42% female. At the time of consultation 87% were hospitalized on general medical services (including hematology/oncology), 4% were on surgical services, 3% on the neurology service, and 6% were in an intensive care unit. Cancer was the primary diagnosis in 52%, AIDS in 24%, with the rest being distributed among cardiac, renal, pulmonary, neurologic, and other diseases. The most prominent physical symptoms were 48% weakness/malaise, 44% pain, 28% dyspnea, and 23% agitation/confusion. The average length of time patients were followed was 2 days (range 1-10). We conclude that a hospice/palliative medicine consultation service sees a broad range of patients and problems and is a rich resource for teaching hospice and palliative medicine.

AIDS and palliative medicine: medical treatment issues.

Caring for patients with AIDS in hospice programs presents numerous challenges. These go beyond the strictly medical decisions discussed in this article to include unique problems with social support, emotional support, and bereavement. This discussion centers on medical issues as they are commonly encountered. They can be stumbling blocks, or even surrogates, for addressing the other important issues at the end of life. Communication between all people involved in the multidisciplinary treatment of these patients is essential. Common goals should be identified and general approaches agreed upon among the physicians, nurses (clinic, hospice, home care), therapists, clergy, and volunteers. In this way we feel that the principles of hospice and palliative care can be effectively applied to most patients with endstage AIDS.

AIDS and hospice.

Which AIDS patients should be admitted to hospice programs? Many health care professionals feel that any anti-viral drug or treatment directed against the opportunistic infections characteristic of AIDS to be incompatible with hospice philosophy. Others argue that inclusion of AIDS patients blurs the distinction between hospice and community service programs. We argue that achieving consensus on this issue is best served by focusing on the defining characteristic of hospice programs--the care of the dying. Consensus is not served by dwelling on the specific palliative or supportive measures used to achieve the hospice goal. We suggest a framework by which AIDS patients may be accommodated in existing hospice programs while maintaining hospice program integrity. It is further suggested that these may be used for the consideration of any patient for hospice care.

Hospice and palliative care: attitudes and practices of the physician faculty of an academic hospital.

It has been suggested that physicians, particularly in academic hospitals, are resistant to the hospice approach to palliative care for terminally ill patients. It is of interest, therefore, to assess the attitudes and practices of the physician faculty of an academic hospital where a hospice program has been in existence for more than 10 years. This was assessed with two faculty surveys. All 966 physician faculty that were on staff at Northwestern Memorial Hospital in the fall of 1993 were sent a survey about their opinion of hospice care (Survey A). Then, all physicians who had referred patients to the hospice program between September 1993 and September 1994 at Northwestern Memorial Hospital received a survey letter after the death of their patient (Survey B). Seventy-seven percent of faculty physician respondents to Survey A had either referred patients, or knew of colleagues who had referred patients to a hospice program. Ninety-four percent of those who answered "yes" to the question about referrals reported satisfaction with their care. Ninety-four percent would refer patients in the future and 96 percent thought the hospice program was a valuable resource to the medical center. Of the respondents to Survey B, nearly 100 percent thought the referral had been handled in an "excellent" or "good" fashion, that communication with hospice staff was "excellent" or "good," that symptom control was "excellent" or "good," that their patients and families had received "excellent" or "good" psychosocial support, and that their patients and families were satisfied with the hospice care they received.(ABSTRACT TRUNCATED AT 250 WORDS)