Hospice Care vs Palliative Care

Transcription

1 Hospice Care vs Palliative Care Easing the burden of illness, Improving quality of life Seasons Hospice and Palliative Care Cheryl Ledesma, FNP-BC Jacklyn Griffin, ACNP-BC Objectives After completing this course the learner will be able to: Define Palliative Care Explain how Palliative Care differs from Hospice List common conditions and symptoms treated by Palliative Care 1

2 Palliative Care Defined Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative Care Defined Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family. 2

3 Palliative Care Defined Palliative care is provided by a team of palliative care doctors, nurses, social workers and others who work together with a patient s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment. Palliative care: Provides relief from pain and other distressing symptoms; Affirms life and regards dying as a normal process; Intends neither to hasten or postpone death; Integrates the psychological and spiritual aspects of patient care; 3

4 Offers a support system to help patients live as actively as possible until death; Offers a support system to help the family cope during the patients illness and in their own bereavement; Uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated; Will enhance quality of life, and may also positively influence the course of illness; Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications. 4

5 Palliative Care and Hospice Differences Palliative Care Hospice Comparable to a house call practice or a subspecialist (such as cardiology or pulmonology) Medicare benefit program Consults / visits provided by MD or NP for symptom management related to an advanced illness Services provided by interdisciplinary team including physicians, nurses, social workers, chaplains, music therapists, home health aides, volunteers, etc. Visits occur anywhere from every day to once per month based on clinical needs. Visits occur usually twice per week by nurse, and twice per week by home health aide. Physicians visit PRN. Continued next slide 5

6 Palliative Care and Hospice Differences Palliative Care Hospice No requirement for prognosis of less than 6 months Required to have a prognosis of 6 months or less Services are consultation based. Curative measures can be maintained (chemo, radiation, surgeries, dialysis, etc.) Services are comprehensive and include DME, medications related to terminal diagnosis, 24 hour support Patient can be accessing home health or skilled nursing days Patients forego skilled rehab, home health and curative treatments Continued next slide Palliative Care and Hospice Differences Palliative Care Hospice Billed through Medicare Part B Billed through Medicare Part A Palliative specialist receives Medicare, Medicaid and private insurance reimbursement depending on billing code (CPT and ICD-10) Hospice receives a per diem rate from Medicare depending on the level of care (4 levels) Patient is responsible for copay based on consultation rate Insurance reimburses case-by-case, carve out for certain treatments, such as TPN 6

7 Palliative Care Can be provided along with other therapies intended to prolong life, such as chemotherapy or radiation therapy Includes those tests or investigations needed to better understand and manage distressing clinical complications Important to note: patient can have a life expectancy of more than 6 months but still have a chronic and ultimately terminal illness Chronic Illnesses Addressed by Palliative Care include: Cancer Congestive heart failure Chronic kidney disease Chronic pulmonary disease Dementia (unspecified and Alzheimer-type) Liver disease Cerebrovascular disease/cva Parkinson s disease HIV/AIDS 7

8 What is Our Goal at the End of Life? Palliative Care vs Hospice Elderly female with past medical history of end stage COPD status post multiple hospitalizations Goals of care included maximal independence, peaceful end of life, refer to hospice once skilled days have been exhausted Symptoms included debility and dyspnea Advanced directives needed to be addressed and updated Would this patient be more appropriate for palliative care or hospice care? 8

9 Palliative Care vs Hospice 65 year old female with past medical history of newly diagnosed small cell lung cancer, presented to ED with complaints of SOB Chest x-ray shows right lung completed whited out, EGD shows advancing mass compressing right bronchus with right lung completed obstructed Complete opacification of right lung Elective intubation next day due to worsening respiratory status Goals of care included palliative radiation to right lung and chemotherapy with end goal of extubation and discharge to LTC/SAR Symptoms include dyspnea and debility Advanced directives needed to be addressed and updated Palliative Care vs Hospice 63 year old women who was diagnosed with lung cancer Not aware that she was stage 4 until a new oncologist took on her case Wanted to continue radiation therapy even though she was very weak and in a lot of pain She had goals to get affairs in order Difficulty eating due to dyspnea Would this patient be more appropriate for palliative care or hospice care? 9

10 Palliative Care vs Hospice 101 year old female with dementia and Grade I congestive heart failure on palliative care service for over one year Stable until September 2016 when she sustained a couple of falls and began intermittent wandering at night November 2016 suffered a right femur fracture and underwent an ORIF Post- operatively suffered from increased lethargy, albumin dropped below 2 Decrease in functionality Would this patient be more appropriate for palliative care or hospice care? Potential Palliative Conditions The Usual Suspects progressive life-limiting illness Incurable cancer Progressive, advanced organ failure (heart, lung, kidney, liver) Advanced neurodegenerative illness (ALS, Alzheimer s Disease) Sudden fatal medical condition Acute stroke Withholding or withdrawing life-sustaining interventions (ventilation, dialysis, pressors, food/fluids ) Trauma eg. head injury Ischemic limbs, gut Post-cardiac arrest ischemic encephalopathy etc 10

11 Symptoms often managed by Palliative Care: Pain Dyspnea Nausea and Vomiting Cachexia and Anorexia Pruritus Anxiety/Depression Delirium Constipation Restlessness and agitation Sleep disorders Fatigue Positive Impact of Palliative Care Involvement 91 year old female diagnosed with CHF, renal failure and COPD % ejection fraction Oxygen dependent 4L NC, desat without NC O2 Hospitalized for edema of lower extremities Returned to facility with a LifeVest Family/resident were told that LifeVest would improve heart function 11

12 Positive Impact of Palliative Care Involvement 89 year old women diagnosed with dementia Having syncopal episodes at Memory Care Unit Palliative Care NP found out that episodes were occurring primarily in the morning Palliative Care NP collaborated with attending MD to change long acting beta blocker from being given in the evening to being given in the morning (with parameters) No further syncopal episodes Avoided injury, hospitalization, workup and overall improved quality of life. Positive Impact of Palliative Care Involvement 55 year old female with early onset of Alzheimers with behavioral issues. Past medical history of bipolar disorder, post traumatic stress disorder and obsessive compulsive disorder Goals of care are psychological comfort (improved behaviors and compliance) Symptom of increased agitation Weight loss Full code 12

13 Potential Palliative Care Interventions Palliative Support Emotional Spiritual Psychosocial Control of Pain Dyspnea Nausea Vomiting Variable Transfusions Infections Hypercalcemia Tube Feeding Dialysis CPR Ventilation Highly burdensome Interventions Generally Not Palliative Advanced Care Planning/Goals of Care Health care proxy/surrogate decision maker Establishing wishes in the event of serious illness or acute event Clarifying code status Family meetings Communication/Documentation of patient wishes to the rest of the health care team. 13

14 Palliative Care Triggers You would not be surprised if the resident/patient died within months You re aware the resident/patient has 3 or more chronic illnesses and is on multiple medications You ve noticed the residents/patients goals of care re inconsistent, he/she lacks an advanced directive, or there s disagreement among family members about the plan of care 14

15 Palliative Care Triggers You ve had to send the resident/patient to the hospital at least twice in the last 6 months You ve had trouble controlling the resident s/patient s physical or psychological symptoms You ve noticed the resident/patient is becoming more difficult to feed, is losing weight, or has a declining functional status Overall Benefit of Palliative Care Consultations Reduced symptom burden of chronic/terminal illness Early integration of palliative care may prevent the use of aggressive care in outpatient settings Identifies goals of care and advocates for patient wishes Cost avoidance Increase in quality of life 15

16 References Alexander, K., Goldberg, J., & Korc-Grodzicki, B. (2016). Palliative care and symptom management in older patients with cancer. Clinics in Geriatric Medicine, 32, Bushor, L., & Rowser, M. (2015, August). Symptom management of adult chronic illness in the outpatient setting. Journal of Hospice & Palliative Medicine, 17, Buss, M. K., Rock, L. K., & McCarthy, E. P. (2017, February). Understanding hospice and palliative care: A guide for primary care providers. Mayo Clinic Proceedings, 92, Center to Advance Palliative Care. Palliative Care definition References Dahlin, C., Coyne, P. J., & Ferrell, B. R. (Eds.). (2016). Advanced practice palliative nursing. New York, NY: Oxford University Press. 6. Miller, S. C., Lima, J. C., Intrator, O., Martin, E., Bull, J., & Hanson, L. C. (2016, September 19). Palliative Care Consultations in Nursing Homes and Reductions in acute care use and potentially burdensome end-of-life transitions. Journal of the American Geriatrics Society, 64, World Health Organization (WHO) Definition of Palliative Care. (2017). Retrieved from 16

17 Contact Information Jacklyn Griffin- Cheryl Ledesma- 17