The diagnosis of a terminal illness brings with it a host of questions, fears and concerns: “Will I be able to handle the pain?” “How will my family care for me?” “How can I afford quality end-of-life care?” And the question we hear most frequently: “Can I stay at home?”

Faced with a life-limiting prognosis, some 90 percent of patients prefer to remain in their homes, using the bed they know, surrounded by people they love, continuing the routines that make them comfortable. Whether they live in their family home, an adult living community or a nursing home, they want to age—and die—in place.
 
For terminally ill patients, hospice makes that possible. Hospice patients are cared for by an interdisciplinary team of hospice experts, including a physician, nurses, hospice aides, social workers, chaplains and volunteers who provide medical care, spiritual, social and emotional support to terminally ill patients and their families.
 
“Hospice care typically is provided in a patient’s home. This allows the patient to stay in a familiar setting surrounded by family and friends,” says Patty Perry, R.N., patient care administrator for VITAS Innovative Hospice Care® of Miami-Dade/Monroe.
Yet the perception persists that hospice means going to—or ending up in—a place. Hospice isn’t a place. Hospice is a philosophy of care; it focuses on enhancing a patient’s comfort and overall quality of life during the last months of life. By treating physical symptoms and providing pain management, as well as addressing emotional and spiritual concerns, hospice can make the dying process more meaningful for patients and their loved ones.
 
When There’s a Crisis, There’s Continuous Care
But what happens when the patient has a medical crisis and experiences, for example, uncontrolled pain, intractable nausea, uncontrolled bleeding or severe confusion? Even then, hospice offers options to help the patient remain at home.
 
“Patients often experience acute symptoms when dealing with a terminal illness, as well as emotional, spiritual and psychosocial challenges,” says Rosario Salas, RN, CHPN. “This can make it difficult for patients to continue to receive care in their residence and it can be overwhelming for family members. But when things get difficult, VITAS can be there around the clock.”
 
VITAS provides Intensive Comfort CareSM—a service (referred to by the Medicare Hospice Benefit as “continuous care”) that puts a trained nurse or home health aide at the bedside up to 24 hours a day.
 
“It means a hospice patient doesn’t have to choose between the comforts of home and care at a hospital,” says Rosario, who, as a VITAS patient care administrator in Broward County, oversees that program’s Intensive Comfort Care teams.
 
“When the patient is most vulnerable to confusion or disorientation, VITAS Intensive Comfort CareSM keeps her in familiar surroundings. She feels at home and calm, surrounded by her own things and with her loved ones near,” says Nadine Brimo, R.N., team manager for VITAS Innovative Hospice Care® of Palm Beach County home care team. “Our staff also helps to ease the fears and feelings of helplessness family members may experience at such a time. The patient gets the care she needs, and the family gets the support and guidance they need too.”
 
 
 


With heart disease the nation’s number one killer, the University of Miami Health System (UHealth) has made cardiovascular care a top priority. In fact, over the past 12 months, the Miller School of Medicine’s Cardiovascular Division has witnessed great strides in all areas, from groundbreaking research to the addition of renowned cardiologists, updated patient facilities and state-of-the-art technology, all coming together to make the University of Miami home to a cardiovascular powerhouse.

Joshua M. Hare, M.D., chief of the Cardiovascular Division, has launched two first-of-their-kind clinical trials, using mesenchymal stem cells to treat damage caused by either heart failure or a heart attack. In the first trial, funded by the NIH, patients are injected with either their own mesenchymal stem cells or a placebo during open heart surgery. The second trial, which started in October, involves using a spiral shaped catheter to inject the cells. Alan W. Heldman, M.D., vice chief for new programs and translational medicine in the Cardiovascular Division and an interventional cardiologist, has been a pioneer in using the Biocardia Helical Injection Catheter in preclinical studies for four years.

“The implications for this kind of therapy are enormous when you consider that nearly five million Americans suffer from heart failure and 500,000 new cases are diagnosed each year,” says Hare, who is also the director of the Interdisciplinary Stem Cell Institute. “We are very optimistic because we have experimental data that show very clearly the cells we are using do have the ability to turn into new heart muscle cells.”

William O’Neill, M.D., executive dean for clinical affairs and a renowned interventional cardiologist, worked with Heldman to start Florida’s first clinical trial using the percutaneous aortic valve replacement system. The minimally invasive procedure involves crimping the transcatheter heart valve onto a balloon delivery catheter, then threading it through the patient’s circulatory system from the leg. It’s particularly effective for avoiding lengthy open-heart surgery which can be risky in older patients. Last April, just one day after the procedure was performed on two South Florida men in their 80s, both were eager to return to regular activities.

To build on its already distinguished electrophysiology team, the Miller School has brought in a new group of experts who are treating heart rhythm disorders in a state-of-the-art lab at University of Miami Hospital. The UM team is focused on using catheter ablation in the treatment of complex cardiac arrhythmia, including atrial fibrillation and ventricular tachycardia. Resynchronization therapies are also being used in the treatment of congestive heart failure.

Patients who need a heart transplant can count on UM doctors for compassionate care with the highest degree of skill. Working with Jackson Memorial Hospital since 1986, the cardiac transplantation program continues to expand, providing lifesaving surgery to patients.

The University of Miami Hospital is also home to HeartAware, an easy-to-use screening program that can quickly identify a patient’s potential cardiac risk. The goal is to flag those patients for follow-up care before a life-threatening event. “If we can identify people who are at risk for a coronary event,” says O’Neill, who helped design the national screening test, “we can treat them before they wind up in the emergency room.”

“Right now we are at a major transition point in medicine. We are currently reaping the benefits of decades of scientific work that has yielded major new approaches to treating cardiovascular disorders,” says Hare. “The Cardiovascular Division at UM is dedicated to delivering the highest quality of care to patients while at the same time being on the cutting-edge of new therapies.”



Ira Stein, M.D.

Dr. Ira Stein is one of only two Pediatric Otolaryngology sub-specialists in the North Palm Beach County area. On a daily basis, Dr. Stein exhibits strength, support and commitment to his young patients, their families and our community.

Dr. Stein has been Chief of Staff at Palms West Hospital for the last two years and prior to that he was our Vice Chief of Staff and our Credentials Chairman. He oversees the Medical Staff and works with the Administrative Team to assist with the growth of the Hospital including the dedication of The Children’s Hospital at Palms West. Dr. Stein has also chaired the Continuing Medical Education Committee and provided numerous lectures to our residents to further their education.

Dr. Stein is an integral part of our community in that he attends to emergency room patients even when not scheduled to provide emergency room call coverage. He sacrifices time with his own family to care for the children of our community. Shannon Fox-Levine, M.D., local pediatrician, describes Dr. Stein as a “physician who has a wonderful bedside manner. Parents feel like he cares about the decision that he includes them in as far as surgery vs. wait and watch approach. He always makes room to see patients we are concerned about in the office, even the same day to ease our minds, as well as the parents.”

Dr. Stein is also a provider for Children’s Medical Services, which is a program that provides a family-centered and coordinated system of care for children with special health care needs. Dr. Stein travels to Ft. Pierce once a month to provide quality care to these children who need it most.

Palms West Hospital is lucky to have such a dedicated physician, as Dr. Stein, involved in our leadership and in our community.



For more than 20 years, Patrick M.J. Hutton, M.D., MBA, has been a member of the Florida Orthopaedic Society (FOS). Now its new president, he is looking forward to leading the organization’s educational efforts in the state and participating in legislative and lobbying efforts.

“One of the issues that is very important to the Florida Orthopaedic Society is improving access to musculoskeletal care for patients in Florida, and I have made that one of my goals,” he explained. “I also plan to be involved in the healthcare reform that is coming on a national level; helping orthopaedic surgeons in the state deal with reform changes by finding the best ways to help them with practice management issues.”

As a member of the American Academy of Orthopaedic Surgeons (AAOS), which has a very close working relationship with FOS, Dr. Hutton is also involved in a program to improve culturally competent care. “Our goal is to make physicians aware of opportunities that are introduced through residency programs in the state to improve diversity in the orthopaedic profession, which in turn, improves care to our patients,” he said. In addition to providing information in a guidebook and CD-ROM, the Academy provides training seminars to residency programs, and the course will soon be available to orthopaedic surgeons online.

“We have a diverse patient population in Florida; instead of talking about a minority population, we’re actually talking about an emerging majority population,” he continued. “The Hispanic, African-Americans and Pacific Rim populations are increasing at a faster rate than the traditional white population in the state.”

According to Dr. Hutton, a person’s cultural background may determine how they accept care. “If I say something to a person from Georgia, it may mean something different to someone in New York state, or Puerto Rico, or Mexico or Manila,” he explained. “We need to tailor our care; even if we’re providing the same care to all of our patients, it doesn’t mean that we’re giving equally good care to everyone.”

Dr. Hutton also plans to participate in the Wounded Warriors Project, whose national headquarters is based in Jacksonville, Florida. “The Academy already has an Extremity War Injury Program, and we would like to tie that into the Wounded Warriors Project in order to help returning veterans adjust to civilian life once they are discharged from the military,” he said.

“There have been major strides made in war injuries research—injuries that soldiers would not have survived in Vietnam, they can now survive,” he added. “Because of better body armor, we are seeing more extremity injuries. There are a lot of advances in what can be done in limb salvage procedures and prosthetics.”

A former flight surgeon in the Navy, Dr. Hutton graduated from St. Joseph’s University in Philadelphia and then attended New York Medical College. He served in the Navy from 1969 to 1995. “There have been a lot of changes in the field since I was an orthopaedic resident in 1978,” he said. “In 1974, arthroscopic surgery had just been introduced in the U.S. –now it constitutes 70 percent of my operative practice. The changes in total joint procedures for hips, knees and shoulders have also advanced remarkably.”

As for the future, Dr. Hutton expects to see even major innovations in medical care, not only in orthopaedics, but across the board. “I think from a technical standpoint, we’ll see advances in antibiotic care and genetically engineered drugs,” he said. “I believe that better biological materials will extend the lifespan of replacement joints, and I also think that we’ll see a dramatic increase in the number of total joint procedures as baby boomers hit their 60s and 70s.”

One concern, however, is that there won’t be enough orthopaedic surgeons in the state to meet this growing demand. “We’re in a bad situation in Florida in that medical school graduates are leaving the state because there aren’t enough residency spots in orthopaedics to take them in,” he said. “Statistics show that 70 percent of physicians practice in the state where they did their residency. In Florida, we’re faced with an aging population and not enough residents, which will cause a real shifting of specialty care in orthopaedics.”

Dr. Hutton plans to work with future FOS presidents to create long-term plans to deal with this and many other issues. “The patient is our primary focus,” he said. “We will work together to provide better, more accessible care for our patients now and in the future.”



Leaders in today’s health care environment must focus on rendering services along the continuum of care for the customers we serve. Simultaneously, leaders must include a strong focus on integrating and arranging an organization that fosters point-of-service accountability and decision-making. It is at point-of-service that most all of the decisions are made and this decision-making is what makes any organization successful. A strong customer focus is the foundation for all activities and job descriptions in the organization. Therefore in order to be successful, we must examine our workforce, structures and model of care delivery systems to enhance that foundation and build upon it. Leaders must focus on resources available to staff while supporting them in their efforts to get the work done.

Accountability is a core standard for leadership and it is imperative that leaders invoke that standard into the standards and expectations of their staff. There must be a shift from the locus of control to accountability and that shift should be directed towards those providing the care. Leaders must take a hard look at the partnership they share with their employees in terms of accountability and be flexible to change in order to partner and support. Staff cannot establish accountability for work that they do not share without direction, control and approval. If accountability and equity are not shared, the system will not support the efforts of the caregivers and staff will never experience ownership to their work. When staff is dependent on their managers to make decisions for them, creativity is stifled. This results in staff lacking motivation and ultimately lacking the most precious buy-in to the processes. It is a leader’s responsibility to ensure that accountability is defined, refined and clear as this is critical for building accountability in any organization at each and every level. Accountability is not given or assigned but rather assumed. Performance expectations must be clear and understood as well as embedded in the job of the employee at the bedside. It is imperative for those delivering the services at the bedside to be aware of both rewards and consequences that are associated with accountability.

Service is so very important to the business of health care which makes it imperative that decision-making and accountability for those decisions is kept at the level they belong. It must not only be clearly understood but clearly owned by the staff or the service delivered will be lacking the substance it deserves. Staff needs empowerment and freedom to serve their customers while the organization should be right there to support their moves. The structures in place for care delivery must reflect the foundation of service as service delivery is built around the customer and not around departments and processes.

Leaders need to take the lead in acquiring new rules for their behaviors to ensure that staff is accountable. There should be no “mom and dad” type relationships, no codependency behaviors, no parental checking and no more taking on other people’s problems. Managers must be much more serving to their staff and less directing. Managers are challenged to become more relationship-oriented with their staff and less distant. And, in the end all of us are challenged to be accountable for what we say and do. Authors B.J. Gallagher and Steve Ventura (2004) wrote about success through personal accountability titled: Who Are “They” Anyway? Here are their ten most important words of personal responsibility that managers should take hold and be sure to share with their staff:

The 10 most important words:
I won’t wait for others to take the first step.

The 9 most important words:
If it is to be, it’s up to me.

The 8 most important words:
If not me, who? If not now, when?

The 7 most important words:
Let me take a shot at it.

The 6 most important words:
I will not pass the buck.

The 5 most important words:
You can count on me.

The 4 most important words:
It IS my job!

The 3 most important words:
Just do it!

The 2 most important words:
I will.

The most important word:
Me

I agree.