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Hospice News Nebraska, Nov. 2, 2017
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Events

Nov. 3 (Fri) - The Nebraska Hospice-Veteran Partnership Annual Workshop and Meeting

Nov. 13 (Monday) - Proclamation Signing

March 20-21 (Tues-Wed) - 2018 NHPCA "Living a Good Life... at the End of Life" Annual Conference

 

Nebraska News


2017 NEBRASKA END-OF-LIFE SURVEY REPORT AND OTHER RESOURCES AVAILABLE

The Nebraska Hospice and Palliative Care Association recently released the 2017 Nebraska End-of-Life Survey Report. Five copies of the report have been mailed to each member agency. A digital version of the report is available for download here. To request additional physical copies, please contact us at info@nehospice.org or 402-477-0204 and we will mail them to you free of charge.

NHPCA has also created a members-only web page full of resources utilizing data from the 2017 Nebraska End-of-Life Survey Report.

Lastly, NHPCA has updated several "Hospice lets me be..." outreach campaign tools with 2017 data. Updated tools are marked with a red "new!" tag.


HOSPICE AND PALLIATIVE CARE PROCLAMATION SIGNING NOV. 13

Governor Pete Ricketts will sign a proclamation to declare November hospice and palliative care awareness month on Monday, Nov. 13, 11:30-noon, in the Governor's Office Suite Meeting Room on the second floor of the Nebraska State Capitol. Everyone is invited to attend. Afterward, the Nebraska Caregivers Coalition will host the annual celebration of caregivers' lunch at the Governor's Residence. The cost for professionals is $25, and reservations are needed by Monday, Nov. 6. For more information or to RSVP, call 402-881-6140 or email Chris Stewart with the Nebraska Caregiver Coalition.


NHPCO LEADING OUTREACH EFFORTS THROUGHOUT NOVEMBER

This month, the National Hospice and Palliative Care Organization is working with hundreds of hospice programs across the country to raise awareness about hospice and palliative care. November is National Hospice and Palliative Care Month, and this year’s theme is “It’s about how you live!”

As part of national outreach efforts, NHPCO is sponsoring a hospice and palliative care Social Media Push on Friday, Nov. 3. This annual event was created to share positive and informational messages about end-of-life care via social media. All supporters and advocates are encouraged to participate using the hashtag #hospiceawareness. Read More


ICD-10-CM-PCS THE NEXT GENERATION OF CODING BOOKLET - REVISED 

A revised ICD-10-CM/PCS The Next Generation of Coding booklet is available. Learn about:

  • International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS), an improved classification system
  • Examples
  • Similarities and differences from ICD-9
  • Current Procedural Terminology and HCPCS codes
  • Use of external cause and unspecified codes; new features; and changes in ICD-10-CM


DIAGNOSIS CODING: USING THE ICD-10-CM WEB-BASED TRAINING COURSE - REMINDER

A Diagnosis Coding: Using the ICD-10-CM Web-Based Training course, with continuing education credit, is available through the Medicare Learning Network Learning Management System. Learn about:

  • International Classification of Diseases, 10th Revision, Clinical Modification/Procedure Coding System (ICD-10-CM/PCS) coding tips, information, and resources
  • ICD-10-CM structure, format, and features
  • How to find correct ICD-10-CM codes


BLOG POST ABOUT NEBRASKA HOSPICE-VETERAN PARTNERSHIP

Nov. 11 is Veterans Day, and in honor of those who have served, Community Health Charities of Nebraska is featuring blog posts about charities that serve veterans. Highlighted in one of these posts is the Nebraska Hospice-Veteran Partnership, a program NHPCA is proud to be part of, that strives to ensure the best possible care for our state's veterans. Read the blog post here.


NIMS/ICS AWARENESS TRAINING COURSES

The Lincoln-Lancaster County Health Department will be presenting an IS-100, IS-200 and IS-700 Awareness Level Training Workshop on Thursday, Nov. 16, as well as Tuesday, Dec. 5, 2017. Whether you are new to emergency planning and preparedness or just need a refresher, this is your chance to receive instruction on the IS-100 Incident Command System, the IS-200 Incident Command System for Single Resources, and the IS-700 National Incident Management System.

There is no fee for this workshop; however, due to limited seating, pre-registration will be required. To pre-register, contact Julie Mach at 402-441-8094 or jmach@lincoln.ne.gov.


SAVE THE DATE FOR 2018 NHPCA ANNUAL CONFERENCE

The 2018 NHPCA "Living a Good Life... at the End of Life" Annual Conference will take place March 20-21, 2018, at Embassy Suites in Lincoln. More information will be released in the coming months.


PARTICIPATION EXEMPTION FOR SIZE FORM NOW AVAILABLE

The Participation Exemption for Size Form is now available to complete on the CAHPS Hospice Survey website until Dec. 31, 2017. Please note, exemptions on the basis of size are active for one year only.

The Participation Exemption for Size Form will need to include for calendar year 2016 the number of patients who were discharged alive, the number of patients who died while in hospice care and a count of patients who fell into the following categories:

  • Patients who were discharged alive
  • Decedents:
    • who were under the age of 18
    • who died within 48 hours of admission to hospice care
    • for whom there is no caregiver of record
    • for whom the caregiver is a non-familial legal guardian
    • for whom the caregiver has a foreign (non-U.S. or U.S. Territory) home address
    • whose caregiver requested that they not be contacted

The CAHPS Hospice Survey Project Team will confirm receipt of the Participation Exemption for Size Form. Confirmation of receipt of the Participation Exemption for Size Form does not constitute approval or denial of this request. CMS will determine the eligibility for size exemption in 2018 when CMS reviews all hospices' data to see if they met the fiscal year 2019 Annual Payment Update (APU). If your exemption is accepted, you will not face a two percent reduction. However, if CMS data indicates you have served 50 or more survey-eligible patients in 2016, you would not qualify for the exemption and in that instance, you would face the reduction. Therefore, it is the responsibility of the hospice submitting the Participation Exemption for Size Form to accurately portray that the hospice meets the fewer than 50 survey-eligible decedents/caregivers for calendar year 2016 and provide the number of patients who died while in hospice care and count of patients who fell into the categories listed on the form.


NEW MEDICARE NUMBER: PREPARE YOUR SYSTEMS FOR APRIL 2018

The Centers for Medicare and Medicaid Services will begin mailing new Medicare cards with a new Medicare number (previously called the Medicare Claim Number on cards) to your patients in April 2018.

Beginning in October 2018, through the transition period, CMS will return your patient’s new Medicare number (Medicare Beneficiary Identifier, or MBI) on every remittance advice for claims you submit with their valid and active Health Insurance Claim Number (HICN). On electronic remittance advice transactions, the MBI will be in the same place you currently get the “changed HICN”: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (Identification Code).

If the vendors you partner with to bill Medicare haven’t shared their MBI system changes with you, contact them to make sure you are both ready for the change; they can also tell you how they will pass the new Medicare number to you.

Visit the Provider web page for the latest information.


Hospice Notes

* What are the unique needs for palliative and hospice care when it comes to Huntington disease? A recent report describes these needs, including “behavioral, psychiatric, movement, and cognitive issues that escalate in late stages of the disease, often overwhelming the abilities of family caregivers.” The article describes specialty palliative care for Huntington disease and comments on the specific aspects of caregiver burnout. (Neurology Advisor)

* Health care law practice experts suggest hospices are likely to see increasing regulatory pressures. Alan Schabes, Esq., of Benesch, Friedlander, Coplan & Aronoff LLP, lays out top compliance risks in several categories: Technology, Live Discharges, Terminal Illness Documentation, and Unbundling of Services. (Home Health)

* An interview with Rabbi Dale Schreiber, who was a chaplain with Barnes-Jewish Hospital and is now with Pathways Hospice and Palliative Care in St. Louis, discusses hospice, planning and the role of the chaplain. “In Judaism, we have this idea that we are not supposed to shorten life, even by a moment, but the other half of that coin is not to prolong dying. That’s a very narrow landscape,” she says, so it’s good to have guidance. “Issues about whether or not we should push somebody to drink or whether we should insist they eat all have to do with what is happening in the immediate process and being able to give families landmarks so they can make the best decisions for the right reasons.” (STL Jewish Light)

* The National Hospice and Palliative Care Organization addresses the overwhelming choices of caring for a seriously ill loved one. Vice President Jon Radulovic points readers toward a free worksheet, “Choosing a Quality Hospice for You or a Loved One.” The document helps patients and families tackle questions when considering hospice care. The document covers Medicare certification, federal surveys, accreditation, after-hours care, and other topics. The press release directs readers to NHPCO’s CaringInfo.org for more information regarding hospice care or hospice organizations in a specific area. (NHPCO)

* Some hospice patients who wanted to die at home did not want to evacuate their homes during the California wild fires. “They didn’t want to leave because they didn’t realize the severity of the problem,” says Karna Dawson, a social worker with Hospice by the Bay. Caregivers scrambled to convince patients to evacuate. “We’re not talking about dying of your cancer. We’re talking about dying in a fire. And those are two very different deaths.” It took two days to safely relocate patients under disaster guidelines, and many were taken in by shelters, relatives, and assisted living facilities. Hospice by the Bay “[dipped] into its reserves to pay the fees, something the Medicare program does not require.” (KQED)

* Gene-editing technology like CRISPR allows doctors to remove disease-causing genetic mutations. Newsweek examines this process and speculates about the consequences—both miracle-like and globally devastating—that technology could have for the world of medicine. They imagine the health care of the future, 20 to 50 years from now, and touch on ramifications for birth, mental health, emergency medicine, preventive medicine, disease treatment, and end-of-life care. “Hospice centers,” they say, “will be equipped with virtual reality pods that allow patients to visit their most favorite places in the world (the beach, Paris, their home) before death, without leaving their hospital bed.” (Newsweek)


End-of-Life Notes

* More communities are following the model set forward by Beatitudes, a life-planning community from Phoenix. Three not-for-profit New York City communities are among those adopting their approaches that have shown a decrease in hospitalizations, fewer staff call-outs, and increased satisfaction and engagement among residents, staff and families. The hallmarks of the model include: “Palliative care is not just end-of-life care,” “Eliminate the word ‘behavior,’” “Create care plans focused on comfort,” and “Adopt an appropriate way of identifying and treating pain.” (Skilled Nursing)

* What does it mean to die with dignity? In “Death is certain. How you choose to die isn’t,” Mark McLaughlin, MD, tells the stories of two patients who made their own choices in care to answer that question. They “took divergent paths during their final months, yet both left an important legacy. Brittany championed legislation for aid in dying. Paul showed us how dying can be a catalyst for creation, through a child and the written word. Their lives and deaths remind us that the only right answer to the final question is that which comes from within each of us.” (KevinMD)

* Children’s films that include scenes of death could help adults and children come to terms with death, according to new research. “These films can be used as conversation starters for difficult, and what are oftentimes taboo, topics like death and dying,” says Kelly Tenzek, a clinical assistant professor at the University of Buffalo. Tenzek co-authored a paper that analyzed 57 Disney and Pixar films with character deaths that identified four general opportunities, or themes, on which to base an end-of-life discussion. (EurekAlert!, Daily Mail)

* The Center for Practical Bioethics, supported by Pew Charitable Trusts, engaged a small group of Catholic leaders from varying perspectives to explore areas of agreement and to mark challenges surrounding palliative care and advance care planning. The Center writes about this experience and the outcomes, reaffirming the “significance of advance care planning that respects values and preferences of the patient.” They speak of the importance of palliative care as noted in “Pope Francis’ description of it as ‘an expression of the truly human attitude of taking care of one another, especially of those who suffer.’” The center further shares a variety of resources including booklets, manuscripts and audio interviews. (Center for Practical Bioethics)

* End-of-Life University presents an interview with Anne Gordon, Program Coordinator for No One Dies Alone, “a vigil program for dying patients which began at Sacred Heart Medical Center in Eugene in 2001. There are now more than 500 programs in North America and abroad.” The interview, available online at the link below, provides guidance and direction for facilities and individuals wishing to start their own No One Dies Alone programs. (iTeleseminar)

* In a 50-minute segment, Texas Public Radio examines advance care planning. The segment features K.T. Whitehead, an elder law attorney; Sandra Sanchez-Reilly, MD, a professor and palliative medicine section chief at UT Health San Antonio; and Kelly MacLean, a comedian and host of the When You Die podcast. The segment centers around exploring an “inevitable part of human existence” and considering what we need to do legally, medically, and emotionally before the end. (Texas Public Radio)

* In Maryland, church groups have been enlisted in an end-of-life medical planning initiative. The Maryland State Department of Health has funded an initiative that will extend talks about end-of-life plans and medical directives, and provide informational documents to about 500 religious congregants. “To us, churches were an effective way to reach people,” says Susan Francis, deputy director of the Maryland Volunteer Lawyers Service. “We find that people turn to churches when in crisis. There are really hard decisions, potentially life-and-death decisions. When you don’t have an advance health care directive, it is not clear who will make the decisions.” (The Baltimore Sun)

* An article in New York Times focuses on the need for physician input when patients and families make difficult end-of-life care choices. After a clot blocked a blood vessel in a patient’s heart, she’d lost all chance of living independently, something she’d told her family was incredibly important to her. In her case, the family chose to keep her alive in a vegetative state, hoping she would soon recover. After four months of care, she died. “People don’t know what they’re in for,” said the patient’s daughter after the funeral. “It hurt all of us to see her like that.” Sara Manning Peskin, MD, writes about the family’s experience and the importance of informed choices. “In every other part of medicine, doctors make recommendations for medications, lifestyle changes and surgeries,” she says. “We don’t offer cancer patients six different chemotherapy regimens and ask them to weigh the pros and cons. Yet when it comes to end-of-life decisions, doctors are terrified of violating patient autonomy. We are scared of our own medical opinions.” (New York Times)


Palliative Care Notes

* Amid so many stories of opioid overdoses in the U.S., The Atlantic’s “Where the Opioids Go” says, “It’s easy to lose sight of the fact that, in much of the world, many people die in preventable pain.” The article follows a report published in The Lancet that includes an analysis of the global distribution of narcotics, arguing that “a well-functioning and balanced global system must both prevent nonmedical use and misuse of medicines and ensure effective access to essential medicines for palliative care, including opioids for pain relief.” The Atlantic concludes, “Access to morphine at the end of life would seem an area of agreement that transcends ideology—where the suffering of millions of people could be prevented at very little cost. Yet on a global scale, that’s not happening.” (The Atlantic)

* A study published in the Journal of the American College of Cardiology shows patients living with heart failure receive significantly less palliative care than those with other illnesses. This happens in spite of research showing palliative care improves symptom management and quality of life. The study’s author, Dio Kavalieratos, PhD, director of implementation research at the UPMC Palliative and Supportive Institute, says, “We should not be waiting until heart failure patients are eligible for hospice care - in other words truly at the end of life - to start considering palliative options. … With improved education, cardiologists and primary care clinicians can integrate palliative care techniques in their everyday practice.” (News Medical)

* How can we extend end-of-life care to parts of the world that do not have resources or technology to relieve pain? This was the topic of a discussion between two physicians, Dr. John Boll and Dr. Alex Nesbitt, and an engineer, Thomas E. Ask, in Pennsylvania. Boll says only 1-in-10 people who need hospice or palliative care have access. Boll shared about the experiences of caring for patients in rural Tennessee that were hours from the nearest hospice. Nesbitt describes the lack of palliative care in rural Africa and shares a collaboration he took part in to improve regional technology for palliative care. Still, he says, technology doesn’t replace human compassion, and it takes a team of support to offer that end-of-life care. “Humans have empathy. Machines don’t.” (Sun-Gazette)

* A new pilot program in California called Palliative Care Options provides home visits from nurses and 24-hour access via telephone to a care provider for members diagnosed with one of four critical diseases. The program was launched by Health Plan of San Joaquin, which began its palliative care program early in anticipation of the new Medi-Cal benefit scheduled to begin statewide in 2018. Health Plan’s chief medical officer Dr. Lakshmi Dhanvanthari, says this will provide “compassionate care along with chaplain services, social services and behavioral health services.” (Recordnet)

* Palliative care can significantly reduce health costs for those with advanced cancer, finds a study presented at the 2017 Palliative Support Care in Oncology Symposium in California. A matched case-control study of more than 2,500 patients found patients in the palliative care arm had a 28 percent decrease of total care costs, as opposed to those who did not receive consultations. Further, the results showed patients experienced more relief the earlier they received the consultation. (Oncology Nurse Advisor)


Advance Care Planning Notes

* The death of Tom Petty has given rise to a broader public discussion of end-of-life planning. After suffering a heart attack at his home, Petty was hospitalized and placed on life support. His family followed his pre-established wishes and do-not-resuscitate order to remove him from life support. CNBC pivots from this specific case to talk about the broader issue. Carolyn McClanahan, a physician and director of financial planning at Life Planning Partners, urges anyone over the age of 18 to make arrangements for their care, citing a statistic that only 26 percent of adults have an advance directive. “You have some massive thing happen to you and it leaves you being a person you don't want to be,” McClanahan says. “That's the No. 1 reason you need advance directives.” Of Petty, she comments, “He set his own rules.” (CNBC)

* Consumer Affairs urges readers to avoid the worst-case scenarios of aging populations by having conversations about end-of-life care preferences. The article recommends “starting a conversation” to develop informed decisions, and includes prices and time considerations for a care planning visit available through Medicare. It reminds readers that advance care planning is “not just for the old or infirm.” “Ideally, advance care planning is a process you revisit throughout your life, continually evaluating what's important to you and what your priorities are,” says Professor Benjamin Levi of Penn State Hershey. “As soon as someone becomes an adult, they should start thinking about these things.” (Consumer Affairs)

* The California Healthcare Foundation reports 90 percent of Americans say talking to those they love about end-of-life care is important, but only 27 percent have initiated those conversations. Linda Trowbridge, CEO of Center for Elders’ Independence, suggests that conversations occur throughout a lifetime, and notes answers often change as people age. “Injury and disease can happen at any point, and young or old,” she notes, “It’s best to be prepared.” (Oakland Post)

* The Conversation Project has updated "How to Talk to Your Doctor," a guide to discussing end-of-life care with doctors, nurses or other health care providers. The guide addresses basic steps that span the entire process (“Get Ready,” “Get Set,” “Go,” and “Keep Going”). It can be used as a workbook to make notes with a health care team. (The Conversation Project)

“Is end-of-life planning truly necessary?” appears in Medical Economics. “We are quickly moving to a health care payment system based on value and outcome,” says Jean Acevedo, a health care billing and compliance consultant in Delray Beach, Florida. She goes on to say, “Any service that can help patients make personal decisions about their health care, based on how much aggressive treatment they are likely to want or not want in those situations, is a good thing.” The article concludes by providing information on advance directives and the conversations that surround them. (Medical Economics)


Other Notes

* “Death Cleaning,” a concept derived from the Swedish word dostadning, which combines the words for death and cleaning, may provide a way to leave a manageable legacy. Swedish artist Margareta Magnusson describes the process in her new book, "The Gentle Art of Swedish Death Cleaning." She sees the task not as morbid, but affirming; and she encourages elders to give their things away to those who will enjoy them. The process of dealing with material things before death overlaps those of Mari Kondo, who encourages an examination of objects and an embrace of those that spark joy. (Time)

* “How long can I go on?” is a question caregivers sometimes find themselves asking. In “Caregiver Burden: Help Carrying the Load,” the author offers four options to help ease the caretaking burden: In-Home Care; Support Groups; Adult Day Care; and, Residential Care or Assisted Living. (U.S. News)

* After the mass shooting in Las Vegas, a local hospice is providing free grief counseling. Nathan Adelson Hospice will offer the sessions on the evening of Nov. 21 and has established a 24-hour crisis hotline for people seeking help. The public can call 877-941-8079 for counseling referrals. (Review Journal)

* “Americans Are Retiring Later, Dying Sooner and Sicker In-Between,” Bloomberg reports. The assessment is made from data from the Society of Actuaries from 1980-2015. They report almost one in three Americans between ages 65 and 69 is still working. Americans in their late 50s also show more serious health problems than people of the same age did 10 to 15 years prior, according to Health Affairs. Bloomberg writes, “Cognitive skills have also declined over time. For those with a retirement age of 66, 11 percent already had some kind of dementia or other cognitive decline at age 58 to 60, according to the study. That’s up from 9.5 percent of Americans just a few years older, with a retirement age between 65 and 66.” (Bloomberg)

* One in six employees is also a caregiver for a family member or friend, so how should employers support them? Northeast Business Group on Health (NEBGH) and AARP launched the first human resources guide of its kind — Supporting Caregivers in the Workplace: A Practical Guide for Employers. For companies, the guide may allow them to “reap rewards in the form of an engaged and productive workforce, a competitive edge in retaining and recruiting employees, a reduction in health care costs, and an increase in employee loyalty.” Employees at the companies could hope to benefit from benefits tailored to caregivers’ specific needs. (Northeast Business Group on Health)


A VOLUNTEER RURAL HOSPICE HAS OFFERED FREE CARE FOR MORE THAN 40 YEARS

The U.S. has more than 4,000 hospices receiving Medicare payments that total nearly $16 billion annually. NPR recently shared the story of a small volunteer hospice in Port Angeles, Washington. The program is an outlier, refusing federal funding or private insurance to provide free care for 40 years. Rose Crumb founded the remote facility in 1978. Crumb worked as a nurse until her mid-80s and now, at 91, continues to oversee a large but mostly volunteer staff that’s driven by community donations. Read More


CAN FAITH COMMUNITIES FACILITATE END-OF-LIFE CONVERSATIONS?

Advance care planning is a medical and legal process guided by the information at hand, and based on personal values. But for many, lack of planning leads to an inability to express those choices when they matter most. For people of faith, the process of planning care in the case of serious or life-limiting diseases is informed by additional considerations of religious practice. In September, PEW Charitable Trusts released “How Faith Communities Facilitate Conversations Around End-of-Life Concerns,” a document focused on the interviews that were conducted in order to better understand the relationship between faith communities and dying, and to explore what this relationship could become. Read More


LEADERS ASK HOW WE ENSURE PALLIATIVE CARE IS A PART OF COMPLETE TREATMENT

For many patients, the distinction between hospice and palliative care becomes blurred. On Oct. 23, Medscape posted a June 2017 discussion it held on Facebook Live. The presentation is titled “The Difference Between Palliative Care and Hospice.” Arefa Cassoobhoy, MD, MPH, host, spoke with Diane E. Meier, MD, and Suzanne E. Zampetti, RN, MSN, FNP-BC. The leaders share their professional experiences and insights to those who want to be advocates for palliative care. Read More


REPORT CRITICIZES HOSPICE CARE AT LIFE’S END

At the end of life, many families turn to hospice care. But sometimes their requests for help are met with “delays, no-shows and unanswered calls.” An article in Time, developed in collaboration with Kaiser Health News, is titled “‘No One is Coming:’ Investigation Reveals Hospices Abandon Patients at Death’s Door.” The report is based on an analysis of 20,000 records of government investigations “revealing that missed visits and neglect are common for patients dying at home.” Reviewing the more than 3,200 caregiver complaints filed during the past five years, government inspectors found “problems in 759 hospices, with more than half cited for missing visits or other services they had promised to provide at end of life.” Read More


Thanks to Don Pendley for contributions.

Correction: In Volume 21, Number 21 of HNN (Oct. 19), a Home Health Care News article was erroneously cited as saying that 46 percent of 2015 hospice-enrolled Medicare beneficiaries were enrolled at the time of death. In fact, 46 percent of all Medicare decedents were enrolled at the time of death.

Hospice Analytics is the national sponsor of Hospice News Network for 2017. Hospice Analytics is an information-sharing research organization whose mission is to improve hospice utilization and access to quality end-of- life care. For additional information, please call Dr. Cordt Kassner, CEO, at 719-209- 1237 or see www.HospiceAnalytics.com.

Hospice News Network is published 45-47 times a year.  Copyright, 2017.  All rights reserved to HNN subscribers, who may distribute HNN, in whole or part, to provider members of the subscribers’ state organizations.  If readers need further information, they should consult the original source or call their state association office.  HNN exists to provide summaries of local, state and national news coverage of issues that are of interest to hospice leaders.  HNN disclaims all liability for validity of the information.  The information in HNN is compiled from numerous sources and people who access information from HNN should also research original sources.  The information in HNN is not exhaustive and HNN makes no warranty as to the reliability, accuracy, timeliness, usefulness or completeness of the information.  HNN does not and cannot research the communications and materials shared and is not responsible for the content.  If any reader feels that the original source is not accurate, HNN welcomes letters to the editor that may be shared with HNN readers. The views and opinions expressed by HNN articles and notes are not intended to and do not necessarily reflect views and opinions of HNN, the editor, or contributors.  Only subscribing state hospice organizations have rights to distribute HNN and all subscribers understand and agree to the terms stated here.