Course Handouts & Post Test

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1 STROKE/COMA: DISEASE TRAJECTORY AND HOSPICE ELIGIBILITY Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Hospice Education Network Course Handouts & Post Test To download presentation handouts, click on the attachment icon Dr. Maxwell discloses no financial relationships with a commercial entity producing healthcare-related products and/or services. Conflict of interest disclosure and resolution statement is on file with HEN. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. OBJECTIVES At the end of this session, participants will be able to: 1. Identify and utilize the correct LCD, based on the patient s terminal diagnosis 2. Describe clinical documentation criteria based upon LCDs that support clinical eligibility for patients with stroke/coma 3. Describe secondary and comorbid disease(s) conditions associated with stroke/coma 1

2 Stroke Stroke occurs when blood flow to the brain is disrupted. Lack of oxygen to the brain causes brain cells to die. Patients who do not die during the acute hospitalization tend to stabilize with supportive care. Continuous decline in clinical or functional status over time indicates poor prognosis. Classification of Strokes Ischemic Stroke Thrombotic Caused by narrowing (occlusion) of blood vessel in the brain Most common type (60%) Associated with HTN and diabetes Embolic Embolus lodges in and occludes a cerebral artery Rapid occurrence with severe symptoms Classification of Strokes Hemorrhagic Stroke 15% of all strokes Result from bleeding into the brain tissue itself from a ruptured vessel Intracerebral Prognosis poor (50% die w/in weeks) Associated with HTN Subarachnoid Bleeding into the cerebrospinal fluid-filled space usually due to rupture of cerebral aneurysm High morbidity/mortality 2

Clinical Symptoms Symptoms depend on area and amount of brain affected Impaired physical mobility Affect-emotional labiality, depression Communication-aphasia/dysphaia Cognition/intellectual

3 Clinical Symptoms Symptoms depend on area and amount of brain affected Impaired physical mobility Affect-emotional labiality, depression Communication-aphasia/dysphaia Cognition/intellectual function/memory Impaired swallowing Visual field cut/sensory loss Treatment Goals Prevention Drug Therapy Surgical Therapy Rehabilitation Coma Definition Coma: Unarousableunresponsiveness in which the subjects lie with eyes closed. Unable to consciously speak, hear, feel or move. Causes include drug poisoning, stroke, oxygen deprivation due to cardiac arrest, etc. Glasgow Coma Scale-used to examine and determine the depth of coma, track patients progress, and predict outcome as best as possible. 3

Coma Prognosis Outcome depends on the cause, location, severity and extent of neurological damage. Most common cause of death is secondary infection such as pneumonia.

4 Coma Prognosis Outcome depends on the cause, location, severity and extent of neurological damage. Most common cause of death is secondary infection such as pneumonia. Stroke and Coma Secondary and Co-morbid Conditions Secondary conditions Skin breakdown and decubitus ulcers Contractures Constipation associated with immobility Nutritional impairment/weight loss Pain Co-morbid conditions Document ways in which co-morbid conditions impact the terminal disease trajectory. LCD Guidelines for Hospice Eligibility and Recertification for Stroke/Coma NGS LCD Number L25678 CGS LCD Number L32015 NHIC LCD Number L

5 Part III Disease-Specific Guideline Note: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II of the LCD A. KPS / PPS < 70% B. Two or more ADL dependence C. Co-morbidities that contribute to life expectancy of 6 months or less Guidelines for Stroke 1. KPS or PPS of <40% Activity Impaired Degree of ambulation Activity/extent of disease Ability to do self care Food/fluid intake State of consciousness Level of Impairment Mainly in bed Unable to do work; extensive disease Mainly assistance Normal to reduced Fully conscious or drowsy/confused Stroke Guidelines cont d 2. Inability to maintain hydration and caloric intake with one of the following: Weight loss of 10% during previous 6 months or 7.5% in previous 3 months Serum albumin of 2.5 gm/dl or lower Current history of pulmonary aspiration without effective response to speech language pathology intervention Calorie counts documenting inadequate caloric/fluid intake Dysphagia preventing patient from obtaining adequate food/fluids who declines artificial nutrition and hydration 5

6 Guidelines for Stroke cont d 3. Documentation of diagnostic imaging that support poor prognosis: a. Non-traumatic hemorrhagic stroke Large-volume hemorrhage on CT Ventricular extension of hemorrhage Surface area of involvement of hemorrhage 30% of cerebrum Midline shift 1.5 cm. Obstructive hydrocephalus in patient who declines, or is not a candidate for, ventriculoperitoneal shunt Guidelines for Stroke cont d Diagnostic findings continued: b. For thrombotic/embolic stroke: Large anterior infarcts with both cortical and subcortical involvement Large bihemispheric infarcts Basilar artery occlusion Bilateral vertebral artery occlusion Guidelines for Coma The medical criteria listed below would support a terminal prognosis for individuals with a diagnosis of coma (any etiology): 1. Comatose patient with any threeof the following on day three of coma: Abnormal brain stem response Absent verbal response Absent withdrawal response to pain Serum creatinine > 1.5 mg/dl 6

7 Guidelines for Coma cont d Documentation of these factors supporthospice eligibility: 2. Documentation of medical complications, in the context of progressive clinical decline within the previous 12 months: a. Aspiration pneumonia b. Pyelonephritis c. Refractory stage 3-4 decubitus ulcers d. Fever, recurrent after antibiotics Stroke/Coma Guidelines cont d If the patient does not meet bothmedical criteria described in 1 and 2, documentation should describe complicated comorbid conditions contributing and/or a rapid decline. Documentation example (hospice admission) Alberta Thomas, age 86 was found by nursing home staff without a pulse or breathing. She was resuscitated and transferred to X medical center. It was not known how long Ms. Thomas was without oxygen. She was in the ICU for several weeks, but never regained consciousness. Her hospital course was complicated with repeated bouts of aspiration pneumonia, sepsis, and renal failure (Creatinine > 2.5 mg/dl). After meeting with the palliative care team, Ms. Thomas family requested comfort measures only and wanted her transferred back to the nursing home where she resided prior to this event. PEG feedings were d/c d. Co-morbids include HTN, previous MI, diabetes and dementia. 7

8 Supporting Documentation example: is this patient eligible? This is the 2 nd recertification for Mr. Johnson, age 69 who suffered an ischemic stroke 10 mosago. He was transferred to Sunshine Nursing Home and referred to hospice. Mr. Johnson is receiving PEG feedings due to problems eating post CVA. His weight is 182 lbs, up 2 lbsin past month. He has a stage 1 decubitus ulcer on both heels, which are being treated with heel protectors and emollients. He has confusion at night, treated with quetiapine prn. No fever or infections since pre-hospice hospitalization. Wife visits daily. Summary Prognosis for patients with stroke is variable. Some patients stabilize or improve over time. Steady improvement in the patient's functional or physiologic status may indicate that the patient is not terminally ill. It is important to distinguish true recovery of function from the improvement in symptoms and subjective wellbeing that can accompany hospice intervention. Use LCD criteria to guide documentation and eligibility/recertification decisions. Resources Resources American Stroke Association Association of Rehabilitation Nurses National Institute of Neurological Disorders & Stroke National Stroke Association Society for Neuroscience 8

9 Course Evaluation & Post Test Thank you for viewing this course on the Hospice Education Network The course evaluation and post test are available from your course catalog page THANK YOU! Terri Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Inc. Hospice Education Network 9

Neurological Conditions: Disease Trajectory and Hospice Eligibility

Neurological Conditions: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources/HEN Course Materials & Disclosure Course materials including