Hospice Approach to Caring Ellen M. Brown M.D.

Transcription

1 Hospice Approach to Caring Ellen M. Brown M.D.

2 bjectives By the conclusion of this session, attendees will be able to: Explain the hospice philosophy and goals Understand what is covered by the hospice benefit Understand guidelines for hospice eligibility for common non-cancer diagnoses

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4 The only problem with hospice is that you have to be dying to get it. Dr. Michael Levy

5 Patient #1 88 yo woman with Stage 4 adenocarcinoma of the lung and malignant pleural effusion, diagnosed September 2015 after hospitalization in May 2015 and September 2015 for pneumonia PMH: Hypertension, degenerative joint disease Discharge care needs: care and drainage of pleurex catheter Patient previously lived independently with her independence, art classes and time with friends of primary importance Admitted to hospice in ctober 2015 with increasing weakness and a 22 pound weight loss Daughter lives abroad and there is family conflict between patient and local son

6 Patient #1 Hospice Course Decreased drainage from Pleurex catheter to every other day to twice a week to weekly to no drainage Patient asks for pleural catheter removal due to increasing pain at the site Increasing chest pain and shortness of breath relieved by oral morphine solution 10mg, 2-3 times a day Increasing weakness and requires more help with showering. Ambulates slowly with a walker;otherwise independent with ADLS. With MSW assistance, hires caregivers Increases her use of oxygen and using ativan for anxiety March 2016: Patient has lost 15 pounds since admission Sleeping most of the day; has minimal po intake; Dies comfortably after 5 months on hospice

7 Patient #2 87yo man with end stage renal disease Had been receiving dialysis 3x/week for 2 1/2 years Decides to stop dialysis due to no longer being able to do it as an outpatient because of hypotension He is ambulatory, independent in all ADLs and mentally clear.

8 Patient #2 Hospice Course Although ambulatory on admission, he had a rapid decline By day #5, he was bedbound, and somnolent, but easily rousable He had minimal po intake He was receiving methadone 5mg q12h for pain and dyspnea, minimizing the need for other breakthrough opioids All non-comfort meds were discontinued He had haloperidol for hallucinations/delirium Supportive family was vigiling MSW and chaplain provided support to wife and children Patient died comfortably, with son stating, death couldn t have been more peaceful.

9 Hospice Philosophy Death is a natural part of the life cycle Hospice enhances and optimizes quality of life Hospice supports palliation, rather than curative treatment Psychosocial and spiritual pain as significant as physical pain

10 Hospice Philosophy Patient, family, loved ones = unit of care Hospice emphasizes importance of relationship between patient / family and primary care physician Aggressive pain and symptom management

11 Goals of Hospice Continue life with as little disruption as possible Live fully in final months, weeks, days Be as comfortable as possible Attain patient s personal goals

12 Living Longer with Hospice 2007 study: 4,493 patients lived an average 29 days longer with hospice (heart failure: 81 days longer)* Authors: with earlier referral to a hospice program, patients may receive care that results in better management of symptoms, leading to stabilization of their condition and prolonged survival. *Journal of Pain & Symptom Management, March 2007

13 Hospice Facts Modern hospice movement began in London in 1967 by Dame Cicely Saunders First hospice in the U.S. in 1974 Hospice as we know it: Medicare Hospice benefit established in 1982 by Congress Approx hospices in the U.S. today nly 36.5% of hospice patients have cancer Top 3 non-cancer diagnoses: dementia, heart disease, and lung disease

14 Eligibility Probable life expectancy of 6 months or less No longer seeking curative treatment Any diagnosis

15 Medicare Hospice Benefit Four Levels of Care Routine Home Care: 93.8% pt. days General Inpatient Care: 4.8% Continuous Care: 1% Respite Care: 0.4%

16 Medicare Hospice Benefit Recertification Medicare benefit periods 1 st : 90 days 2 nd :90 days 3 rd : 60 days 4 th: Unlimited period (recert every +60 days)

17 Medicare Hospice Benefit Discharge: when patient is no longer appropriate (i.e., doesn t meet criteria) Revocation: patient or family decide to return to non-palliative care

18 Medicare Hospice Benefit Discharge: when patient is no longer appropriate (i.e., doesn t meet criteria) Revocation: patient or family decide to return to non-palliative care

19 Included in Hospice Intermittent visits Medications Equipment Supplies Respite stays Bereavement support

20 Hospice Statistics Hospice cares for approximately 41.6% of all dying patients in US 2014: estimated 1.6 million received services from hospice (NHPC 2015 report) Gallup poll: 88% of people asked preferred to be cared for at home at the end of life

21 Length of Stay 2014 median length of stay: 14 days Down from 18.5 days in : 35.5% of hospice patients died in 7 days or less; and 50.3% die within 14 days of admission 10.3% remained on hospice for longer than 180 days NHPC Facts and Figures on Hospice Care 2015

22 Location of Death Location of Death Patient s Place of Residence 66.6% 58.9% Private Residence 41.7% 35.7% Nursing Home 17.9% 14.5% Residential Facility 7.0% 8.7% Hospice Inpatient Facility 26.4% 31.8% Acute Care Hospital 7.0% 9.3% NHPC 2014 National Data set

23 Debunking Myths Hospice is NT: Giving up hope ne-way street Hastening or delaying death Death sentence Just for final few days Giving up medications

24 Team Approach Patient, family, primary care physician Intermittent visits from Nurse Hospice aide Social worker Volunteer (5% patient hrs mandated by Medicare) Spiritual counselor May not see, but on the case: Pharmacist Medical director Available as needed: Dietitian Physical therapist

25 Advantages For Patient Be at home Expert pain and symptom control Emotional and spiritual support Knowledge that family has support Companionship Extra personal care Comfort therapies

26 Advantages For Family Instruction in end-of-life care Financial relief for cost of meds, equipment, supplies related to the illness Bereavement support for 13 months 24-hour nursing availability Assistance with financial and funeral plans Counseling

27 Advantages For Facility Education on pain and symptom management, other topics relevant to hospice patients Assistance with complicated patients 24-hour hospice nurse availability Extra patient services, e.g. animal assisted activities, personal care Bereavement support

28 Percent of Patients Served by Payer Payer Medicare Hospice Benefit 87.2% 85.5% Managed Care or Private Insurance 6.2% 6.9% Medicaid Hospice Benefit 3.8% 5% Uncompensated or Charity Care 0.9% 0.7% Self Pay 0.8% 0.8% ther Payment Source 1.2% 1.2% NHPC 2014 National Data Set

29 rganizational Tax Status Not-for-profit (charitable organization, subject to 501 (c) 3 tax provisions) For-profit (privately owned or publicly held) Government (owned or operated by federal, state, or local municipality

30 Medicare-certified Hospice Providers 28% not-for-profit 68% for-profit 4% government owned Number of for-profit hospices provider has steadily increased over past 26 years Number of not-for-profit decreasing over same period

31 Cost Savings For Medicare Medicare costs for hospice patients were lower than non-hospice Medicare beneficiaries with similar diagnoses Hospice enrollment is associated with fewer 30 day hospital readmissions and hospital deaths Hospice enrollment is associated with fewer hospital and ICU days

32 Recent Regulatory Changes Face to face encounter: began in 2011 Inability to use debility or failure to thrive as primary diagnosis Inability to use dementia as primary diagnosis

33 Hospice Criteria for Common Diagnoses

34 Heart Disease CHF or angina at rest (NYHA Class IV) ptimal diuretic and vasodilator therapy Tx includes ACE inhibitors May include patients who do not tolerate tx ther factors : Resistant arrhythmias History of cardiac arrest or syncope Cardiogenic embolic stroke HIV

35 Pulmonary Disease Disabling dyspnea at rest Poor response to bronchodilators Bed to chair existence Progressive disease Increasing complications (infections, respiratory failure) Serial decrease >40 ml in 1 second forced expiratory volume (FEV1) over last year

36 Pulmonary Disease Hypoxemia at rest on supplemental 2 (<55mm Hg or <88% saturation) Right sided failure 2 to cor pulmonale Hypercapnia (pc2 >50 mmhg) Weight loss >10% over 6 months Resting tachycardia >100/min

37 End-stage Liver Disease Severely impaired liver function tests Protime > 5 seconds over control Albumin < 2.5 gm/dl Clinical parameters Refractory ascites Hepatic encephalopathy Hepatorenal syndrome Recurrent variceal bleeding

38 End-stage Renal Disease Creatinine clearance < 10 cc/min Serum creatinine > 8 mg/dl (> 6mg/dl in diabetics) Clinical uremia with dialysis ther supporting criteria: liguria < 400cc/day Uremic pericarditis Intractable fluid overload Hyperkalemia

39 Stroke and Chronic Coma Palliative Performance Scale < 40% Unable to maintain hydration and caloric intake with one of following: 10% wt loss over 6 months Serum albumin < 2.5 gm/dl Aspiration not responsive to speech therapy Calorie counts documenting inadequate intake Dysphagia preventing sufficient intake to sustain life

40 Choices

41 Patients Have Choices How does your hospice differ from others? Are you certified by the Joint Commission? What sort of bereavement follow-up programs do you have? How many of your nurses and doctors are certified hospice specialists? If they get a recommendation, tell them to ask why the person recommended that organization.

42 Dame Cicely Saunders You matter until the last moment of your life, and we will do all we can, not only to help you die peacefully, but to LIVE until you die.

43 visit us at Pathwayshealth.org