Hospice May Prolong Life

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2 OBJECTIVES Shatter some myths about Hospice care Revisit difference between Hospice/PC Learn to use a Discussion Guide to clarify GOC Expand the Letterman Technique of Presentation

3 Myths Myth # 20, Prognostic Certainty is Required Myth #19, Entering Hospice is Irreversible Myth #18, Hospice means, stop all previous medications and treatments Myth #17, Hospice means, no treatments Myth #16, Not Ready for Hospice should be taken as final opinion. Myth #15, Not Pursuing Cure will mean an earlier Death

4 Hospice May Prolong Life Connor SR et. al. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage, 2007 Mar,33(3) Temel, J et. al, Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer, N Engl J Med 2010; 363:

5 Myths Myth #14, Lab and X-ray tests are needed to confirm Prognosis. Myth # 13, hospice will come into my home and take over. Myth # 12, hospice will not allow treatment of common illnesses. Myth # 11, hospice is a place to go to die.

6 HOSPICE A place An organization or program An approach to or philosophy of care A system of reimbursement

7 Myths Myth # 10, Hospice is specifically for cancer patients. Myth # 9, Hospice won t accept someone receiving chemotherapy or radiation. Myth #8, Hospice will not accept a patient who is full code.

8 Myths Myth # 7, hospice will not accept a patient who wants IV fluids, tube feeding or antibiotics. Myth # 6, Hospice won t accept patients without a clear terminal diagnosis Myth #5, After 6 months the patient has to be discharged from hospice.

9 Myths Myth #4, hospice patients can t see their own doctor. Myth #3, hospice patients can t be admitted to the hospital. Myth #2, hospice means imminent death

10 Myths Myth #1, hospice doctors think like Dr. Kevorkian.

11 So Who is Appropriate for Hospice? LCD S and the Surprise Question The Gestalt of Frailty PPS Flacker Walter Mortality Risk Index Frailty Score

12 PALLIATIVE CARE Attention to Physical, Emotional, Social and Spiritual Pain= Total Pain (Saunders) Any time during a patient s illness Advanced Symptom management Family Meeting, our chief procedure Hospice = Aggressive Palliative Care

13 What the Family Meeting Does Reviews and corrects understanding of Dz Proactive re: Goals-key questions Explores values and philosophy of suffering Offers prognosis if pt or family requests Addresses ethical issues Psychosocial support TAKES TIME!

14 Palliative Care Myths Myth#1, Palliative Care = End of Life Care Myth#2, Palliative Care=just pain management Myth #3, Palliative Care means no more treatment when nothing more can be done

15 HOSPICE PHILOSOPHY Address Total Pain You matter because you are you, and you matter until the last moment of your life. We will do all we can, not only to help you die peacefully, but also to live until you die.» Cicely Saunders

16 SERIOUS ILLNESS CONVERSATION GUIDE Patient-tested language Creates a safe therapeutic space Intended to be compassionate, open, gentle Copyright 2016 ARIADNE LABS: A Joint Center for Health System Innovation ( labs.org) and Dana Farber Cancer Institute

17 Starting the conversation I m hoping we can talk about where things are with your illness and where they might be goingis this OK? This sets up the conversation. Builds trust and gives control Respectfully requests permission. GOAL= to have the needed info about what matters most

18 How Much do You Want to Know? What is your understanding now of where you are with your illness? What have the doctors told you? Tailor disclosure to the readiness of the pt.,and reality testing

19 How much information about what is likely to be ahead with your illness would you like from me? e.g., I m worried that your time may be short or This may be as strong as you feel What kind of information would be most helpful to you? Titrate What concerns do you have about this? Empathize with difficulty of topic, identify ambivalence, and name the emotion (from Anthony Back, MD s VITAL talk: ADAPT)

20 What are your most important goals if your health situation worsens? What matters most to you? Promotes Hope Antidote to Helplessness or Hopelessness

21 What are your biggest fears and worries about the future with your health? Are there any treatment situations you would want to avoid? Patients feel understood, supported, less alone

22 What gives you the strength as you think about the future with your illness? e.g., Is your faith important to you? Understand and nurture these positive assets A positive counterpoint

23 What abilities are so crucial to you that you can t imagine living without them? QOL- Never Assume! Focus on Function

24 If you become sicker, how much are you willing to go through for the possibility of gaining more time? Assess Philosophy of Suffering Discussion promotes informed decisions

25 How much does your family know about your priorities and wishes? Advance Directive Who is your Surrogate?

26 Summarize and Close It sounds like is very important to you Given your goals and priorities, and what we know about your illness, I recommend * We are in this together (e.g., and will stick by you etc.)

27 The Case of Mr Smith 68 y/o retired salesman COPD; on steroids and home oxygen Comorbidities: DM, CKD, chronic hip pain s/p 3 hospitalizations this year for COPD SX: worsening dyspnea, muscle weakness, fatigue Declining performance status despite rehab Very involved wife and 28 y/o daughter

28 Sample Interview-COPD O_U4&feature=youtu.be

29 How to introduce PC and Hospice to patients and families After the introduction and scripts I just suggested, be prepared : Does this mean that I m dying? Address some of the myths mentioned

30 Benefits of early enrollment Build relationships with team a terrific 24 hour safety net Education about the landscape of illness Equipment and medications provided, delivered Frequent reassessment of Goals of Care Prevent hospitalizations with aggressive symptom and crises management-we take the calls! Time and space for anticipatory grief

31 THANK YOU!! ANY QUESTIONS??