Hospice and Palliative Care for the Elderly

Transcription

1 Hospice and Palliative Care for the Elderly Stephan Stellmacher, DO FACP Internal Medicine Hospice and Palliative Care Medicine Hospice vs. Palliative care + Palliative care seeks to relieve suffering and achieve the best quality of life for patient and family by enlisting a team approach to care. + Palliative care is offered within the Medicare Hospice benefit where prolongation of life is not the direct goal or outside the hospice benefit where life prolonging and curative therapies are still desired and appropriate. 1

2 The Truth Hope is a wonderful thing. False hope can be cruel. Ian Morrison Ph.D., Healthcare Futurist Being Mortal Atul Gawande PBS Frontline 2

3 News Flash Mortality remains = 100 % By its nature the care of the elderly makes this more relevant. Modern Medicine We have come full circle 3

4 Hospice A shelter or lodging for travelers, children or the destitute often maintained by a monastic order Origins of Hospice First hospices traced to 11 th Century, Crusades Places where sick, dying and wounded were taken. Also a place where travelers could stay. Run by nuns and monks Hospice rose in popularity during middle ages but later languished as monastic orders were in decline. Revival in 17 th Century France Flourished from in France In the UK, attention was drawn to the needs of the terminally ill in the middle of the 19th century, with Lancet and the British Medical Journal publishing articles pointing to the need of the impoverished terminally ill for good care and sanitary conditions. Hospices opened in many countries in late 19 th century: UK, US, Ireland, Australia 4

5 The Modern Hospice Era Dame Cicely Saunders: Nurse medical Social Worker Physician. Completed medical school 1957 Introduced the notion of 'total pain' which included psychological and spiritual as well as the physical aspects Toured US to present approach 1963 Opened St Christopher s Hospice 1967 Florence Wald, Dean of Yale School of Nursing worked with Saunders. Opened Hospice Inc. on return in Kubler Ross published On Death and Dying Hospice begins as a grass roots volunteer movement in US The Rise of Hospice in US 1974 First hospice legislation introduced not enacted 1978 US Dpt of HEW: The hospice movement as a concept for the care of terminally ill and their families is a viable concept and one which holds out a means of providing more humane care for Americans dying of terminal illness while possibly reducing costs. As such, it is the proper subject of federal support Congress creates Medicare hospice benefit 1984 American Academy of Hospice and Palliative Care Medicine is formed 5

6 Hospice Utilization in US vs Flagstaff US Hospice Deaths = 42 % Flagstaff Hospice Deaths 140/493 = 28 % 6

7 How Flagstaff Medical Community Compares to the Nation Average length of stay: Nation=69.1 days, Flagstaff=9.5 days Median length of stay: Nation=19.1 days, Flagstaff=6.5 days Median length of stay (days) Flagstaff based on referral source: FMC=6.5, Cancer Center 12.5, Primary care=7. Nationally 39 % of hospice referrals come from hospitals whereas 53% of referrals in Flagstaff come from the hospital. Hospice Provider by Type 7

8 Hospice Utilization Then and Now In % of all Medicare decedents used hospice vs 30.1% in

9 When to Refer to Hospice? EARLY We overestimate life expectancy Families are more satisfied Patients live longer Most patients prefer to die at home Why Refer to Hospice Early? Most physicians overestimate survival: 343 physicians estimated survival for 468 terminal patients Only 20 % of predictions were accurate within 33 % of actual survival 63 % were overoptimistic, 17 % were overly pessimistic Overestimated survival by a factor of 5.3 Non oncology medical specialists were 326 % more likely than general internists to make overly pessimistic predictions Physicians in upper quartile of practice experience were the most accurate As duration of doctor patient relationship increased and time since last contact decreased, prognostic accuracy decreased BMJ 2000; 320: 469 9

10 Why Refer to Hospice Early? Many studies find: Earlier referral improves satisfaction Surveys indicate that families often feel satisfaction would be better if they had been referred earlier Exit surveys do not find that patients and families feel they have been referred too soon J Am Geriatr Soc 53: , 2005, Why Refer to Hospice Early? Most people with a terminal diagnosis prefer to die at home (Palliative Med, (3), ; Journal of Palliative Medicine, (3): ; Palliative Med (5) ) 60 % of deaths in US occur in the hospital (JAGS : ) Early hospice referral allows families and patients to explore and plan for preferences 10

11 Why Utilize Hospice Services Patients live longer Improved satisfaction/quality Lower cost of care Terminal Patients Live Longer with Hospice Care Two studies came to similar conclusions 5 % of all Medicare claims from Total of 4493 patients identified. Journal of Pain and Symptom Management, 33(3), , March Hospice patients lived 29 days longer on average Hospice patients with CHF, lung cancer, pancreatic cancer and colon cancer lived longer while survival for breast and prostate cancer was not significantly different patients who survived for at least three months after dx of lung cancer. Divided into matched hospice and non hospice groups. JPM August 2011, 14(8): One year/two year survival: 25 %/6.9 % for hospice group 20 % /5.5 % for non hospice group. Longer term hospice (defined as > 3 days) outlived non hospice patients Short term hospice outlived non hospice group. 11

12 Satisfaction with Hospice Care Terminal Patients are More Satisfied with Palliative Care than with Usual Care Two small studies Prospective interview of 149 families whose loved ones died at Mount Sinai Medical Center. J Pain Symptom Manage July 36(1): One third received Palliative Care (PC)consultation. 65% of PC vs 35 % of usual care families felt emotional and spiritual needs met 71% of PC vs 46% of usual care families felt significant benefits in self efficacy domains Randomized controlled study, 298 patients with prognosis of one year(copd, CHF or cancer). Looked at satisfaction, utilization, site of death and cost. JAGS 55: , 2007 Intervention group received on call 24/7 in home care with nurse, physician, chaplain, social worker similar to care offered by hospice. Palliative patients were three times more likely to report high levels of satisfaction Cost of care was 33% less in palliative group 75 % of palliative patients died at home vs 51 % in the control group. 12

13 Hospice Improves Satisfaction Four Studies: Randomize controlled trial of hospice care showed increased satisfaction by patients and family caregivers. Family caregivers showed less anxiety. Lancet, April 1984, Mortality follow back survey of families of 1578 decedents comparing death in hospital vs Home with or without hospice services. JAMA 2004; 29(1): % of non hospice patients vs 20 % of hospice patients had insufficient emotional support More than 70 % of hospice vs less than 50% of non hospice families rated care excellent Hospice patients had dyspnea and pain adequately treated at same rates as hospital patients. Both groups did better than home patients without hospice Hospital families were 2 3 times more likely to feel physician communication was inadequate. Mortality follow back survey of 538 families whose loved ones died of Dementia. J Am Geriatr Soc Aug;59(8): Half received hospice care Fewer unmet needs Fewer concerns with quality of care Higher rating of quality of care Better quality of dying Meta analysis of 33 studies from JAGS 56: , of 13 showed a significant effect on satisfaction for collaboration consultation interventions Hospice and palliative teams improved satisfaction 2 of 3 studies found improved satisfaction for heart failure coordination of care Hospice Care Reduces Cost 27 to 30 percent of Medicare payments each year are for the 5 to 6 percent of Medicare beneficiaries who die in that year 40 percent of Medicare dollars cover care for people in the last month of life. End of life care costs in the final week of life are 35.7 % lower in cancer patients who reported having an end of life conversation with physicians. Best study of cost: 5 % sample of Medicare from total patients. J Pain Symptom Manage 2004; 28: Mean cost was lower for hospice care for all 16 diseases studied except prostate cancer, stroke. Lower cost reached statistical significance for CHF, liver cancer and pancreatic cancer Patients who chose hospice had longer time until death by days to months compared to non hospice patients. 13

14 Health Care Costs vs Life Expectancy Services Provided by Hospice Primary Care Provider 14

15 Goods and Services Provided by Hospice Hospice is 100% covered by Medicare and most private insurers (some AHCCCS plans) and includes: Medications related to the terminal diagnosis (no co pay) Medical equipment related to the terminal diagnosis (no co pay) Incontinence and other medical supplies related to terminal diagnosis Respite care In home crisis care Inpatient hospice care Bereavement support for 13 months following death of patient Physical, occupational and speech therapy related to hospice diagnosis Assists the patient with the emotional, psychosocial and spiritual aspects of dying Instructs the family on how to care for the patient Frequent support from social worker Assistance with ALTCS applications, funeral arrangements Volunteer services must equal at least 5 % of total patient care hours regardless of profit or nonprofit status Regular visits (if desired by patient or family) from non denominational chaplain Up to daily visits from RN for assessment and treatment of symptoms CNA visits up to 5 days per week for personal care and hygiene Music therapy Massage therapy Medications in the elderly: Less is more Prospective study 119 nursing home patients with 71 control 12 months Discontinued 332 drugs in 119 patients 1 year mortality was 45 % in control group and 21 % in study group Referral rate to acute care 30 % in control and 11 % in study group medicatoins discontinued included nitrates, iron, h2 blockers, diuretics, blood pressure medications IMAJ 2007;9:

16 HOSPICE PATIENTS DISEASE TRAJECTORIES RAPID DECLINE Cancer SAW-TOOTHED DECLINE Organ system failures (COPD, Heart Failure, etc.) Decline SLOW INSIDIOUS DECLINE Neurodegenerative disorders Dementia Debility Time Resource: Field MJ, Cassel CK (eds), Institute of Medicine. Approaching Death: Improving Care at the End-of-life. Washington, DC: National Academy Press Death How to Identify Patients Eligible for Hospice Care Ask yourself: Would the average clinician think there is a good chance this patient will no longer be alive in 6 months? Hospice is a 6 month benefit. 16

17 Hospice Qualifying Diagnoses Cancer Heart Disease Debility non disease specific/malnutrition Dementia Lung Disease Stroke or Coma Kidney Disease (ESRD) Non ALS Motor Neuron Disease Liver Disease HIV/AIDS Amyotropic Lateral Sclerosis (ALS) Guidelines for Hospice Eligibility Patient has a terminal diagnosis as certified by attending physician with supporting documentation of terminal illness Death is more likely than not within 6 months. Patient/family have been informed of terminal diagnosis Patient/family no longer seeking curative treatment 17

18 Palliative Performance Scale Prospectively validated tool for predicting survival in heterogeneous populations. Hospice Guidelines for Cancer Diagnosis Must be present: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) With either: Disease with distant metastases present (mets not necessary for small cell lung cancer, brain ca and pancreatic). Prostate and Breast cancer tend to be slow moving cancers. Progression from earlier stage of disease to metastatic with either: continued decline in spite of therapy OR Patient declines further directed therapy. Lends support: Presence of co morbid/secondary conditions lends support 18

19 Hospice Guidelines for Heart Disease Should be present: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) Patient is optimally treated. New York Heart Association Class IV symptoms at rest Lends support: EF 20 %, Tx resistant arrhythmias, prior cardiac arrest, unexplained syncope, cva of cardiac origin, HIV disease, High BNP Hospice Guidelines for Non Disease Specific Decline/Debility Must have: Documentation of clinical progression of disease Worsening non reversible decline in clinical status, symptoms, signs and lab results 1. Clinical status Recurrent or intractable infections Progressive wasting: unintentional weight loss, BMI 22, Decreasing limb measurements, decreasing albumin or cholesterol, decreasing food portion consumption Dysphagia leading to recurrent aspiration 2. Symptoms: Intractable dyspnea, cough, nausea and vomiting, diarrhea, pain 3. Signs: SBP below 90, orthostasis, ascites, jaundice, edema, pleural effusions, weakness, ALOC, Fall in FAST, oxygen dependency 4. Lab values that indicate progression: increasing pco2, decreasing SaO2, increasing calcium, creatinine or liver function tests, decreasing creat clearance, falling albumin Decline in PPS Lends Support: Increasing emergency room visits, hospitalizations or physician visits Dependence on two or more ADLs Progressive stage 3 4 pressure ulcers in spite of optimal care 19

20 Hospice Guidelines for Dementia Must Have: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) FAST Score 7c or greater (non ambulatory, incontinent, very little speech) Lends Support: Secondary conditions: Aspiration, pyelo, septicemia, stage 3 4 decubitus ulcers, recurrent fever, weight loss (10 %) or dehydration Functional Assessment Staging Developed by Reisberg in 1984 as a way to describe accurately the stage of dementia Studies do not show ability to predict mortality when used by itself Mortality Risk Index Score is a better predictor of mortality at six months but not widely used by hospice eligibility guidelines 20

21 Hospice Guidelines for Lung Disease Must have: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) Sever chronic lung disease as documented by both disabling dyspnea at rest (bed to chair, fatigue, FEV1<30% of predicted) and end stage disease as evidenced by increasing ER visits, pulm infections, admits With either: Hypoxemia at rest on room air Hypercapnia 50 mmhg Lends Support: Right heart failure/core pulmonale with nml LVEF Weight loss of > 10 % of body weight in prior 6 months Resting tachycardia Hospice Guidelines for Renal Disease Must have: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) Not seeking renal transplantation With either: Creatinine clearance < 10cc/min (<15 cc/min for diabetics) with volume overload Serum creatinine >8.0 mg/dl (>6.0 mg/dl for diabetics) Lends support: ARF with mechanical ventilation, malignancy, COPD, Cardiac disease, Liver disease, sepsis, AIDS, alb 3.5, cachexia, plt <25,000, DIC, GIB) CKD with uremia, intractable hyperkalemia, uremic pericarditis, hepatorenal, oliguria, volume overload 21

22 Hospice Guidelines for Liver Disease Should have: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) PT more than 5 seconds or INR 1.5 Albumin, 2.5 gm/dl ESLD as evidenced by: refractory ascites, SBP, hepatorenal syndrome, refractory hepatic encephalopathy, recurrant variceal bleed Lends support: progressive malnutrition, muscle wasting, continued Etohism, hepatocellular carcinoma, HBsAg positive, Hep C refractory to treatment Other comorbid conditions Special note: may be on hospice if awaiting transplant Hospice Guidelines for ALS Required: PPS 70 % Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) Should have one of the following: Impaired ventilatory capacity (VC < 30 % of nml + dyspnea at rest + declines mechanical ventilation) Rapid progression and critical nutritional impairment Rapid progression and life threatening infections 22

23 Hospice Guidelines for Stroke and Coma Should have: PPS 40 Unable to maintain hydration and caloric intake (>10% weight loss in six months or serum alb < 2.5, pulm aspiration, inadequate po intake to maintain, severe dysphagia) Lends support: Hemorrhagic stroke: large volume, ventricular extension, midline shift > 1.5 cm, obstructive hydrocephalus Thrombotic/embolic stroke: large anterior infarcts, large bihemispheric infarcts, bilateral vertebral artery occlusion, basilar artery occlusion Hospice Guidelines for HIV Should have: PPS 50 Dependence on assistance for two or more ADLs. (feeding, ambulation, continence, transfer, bathing, dressing) CD4+ count, 25 cells/ml or viral load > 100,000 copies/ml One of the following: CNS lymphoma, wasting, MAC bacteremia, unresponsive visceral Kaposi s, renal failure, PMLE, cryptosporidium, unresponsive toxoplasmosis, systemic lymphoma Lends support: Chronic diarrhea, albumin < 2.5, active substance abuse, age > 50, CHF, AIDS dememtia, Toxoplasmosis, advanced liver disease 23

24 Timely and Effective Hospice Discussions: Eliminating Barriers Establish medical facts Set the stage Assess patient understanding of prognosis and what they want to know Define patient goals for care Identify needs for care Introduce hospice if it is appropriate and best option and describe services provided Respond to emotions elicited Refer to hospice if patient and family desire 24