Why Hospice and why now?

Transcription

1 Why Hospice and why now? DAVID BEST, DO JUNE 14, 2018 NMOA SUMMER CONFERENCE MACKINAC ISLAND

2 Disclosres Heartland Hospice Team Physician, Janary 2013 to present My Dad died on April 14, 2008 at age 71 almost 2 years after diagnosis of lng cancer. He was on hospice for the last 3 weeks with Angela Hospice. I spent the last 9 days living with him and my Mom. My brother helped as my intern and we had my son s 2 year old birthday party at the hose.

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4 Objectives 1.) Understand Hospice Eligibility Criteria 2.) Understand Hospice Team Member Responsibilities 3.) Understand Goals of Hospice Care and Palliative Care 4.) Discssion of how hospice can improve qality of life for patients and their families. 5.) Osteopathic Principles

5 Why Hospice, Why Now? Hospice is a covered benefit for patient with terminal illness and less than 6 month life expectancy if disease follows its normal corse. Hospice care is meant to: Provide relief of sffering to patients Redce caregiver brden and stress Give patients and their families permission to stop ftile care Simplify care and provide edcation to patients and families Allow patients to stay in their home Landing the plane smoothly vs. crash and brn

6 Local Coverage Determination (LCD) Set of criteria for different illnesses CHF COPD Cancer CAD ESRD Dementia CVA ALS

7 KPS, PPS, FAST Scores Karnofsky Performance Scale Palliative Performance Scale Fnctional Assessment Staging Test

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10 FAST Score for all dementias Alzheimer's Vasclar Picks Lewy Body NOS!

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12 Activities of Daily Living Docment Dependence on assistance for ADLs: Amblation Toileting Transfer Dressing Feeding Bathing

13 Co-Morbidities are important What other diagnoses are contribting to 6 month of less prognosis CHF COPD CAD Diabetes CVA Renal Failre Liver Disease Neoplasm Dementia

14 Specific Symptoms for each disease process Amyotrophic Lateral Sclerosis (ALS) Patient for example: Dyspnea at rest Orthopnea Use of accessory mscles Redced speech volme Weakened cogh Excessive sleepiness Unexplained headaches, confsion, anxiety or nasea Dysphagia with weight loss of at least 5%

15 LCD for Heart Disease example Decline in Clinical Stats: Symptoms: dyspnea, intractable cogh, pain, N/V/D Signs: systolic BP <90, edema, weakness, change in consciosness KPS or PPS less than 70% Reqires assist with ADLs History of increasing ER visits, hospitalizations, or physician visits NHYA Class IV: Pt. has SOB with any activity, has been on optimal medical therapy and is not a candidate for any procedres.

16 Team Members Clergy or other conselors; Home health aides; Hospice physician (or medical director); Nrses; Administrators Clerical Staff Social workers; Trained volnteers; Speech, physical, and occpational therapists, if needed; The person's personal physician may also be inclded.

17 Case review at least every two weeks Interdisciplinary Grop (IDG) Meetings Nrses Social worker Clergy Volnteer coordinator Administrator

18 IDG Meetings Reflection Bereavement reports New patient review Re-certifying patient review After 90 days and 180 days then every 60 days After 180 days face to face visit by Physician or Nrse Practitioner is needed every 60 days All other patients for nrse(s) team

19 Nrses The palliative care nrse works with other members of the IDG to develop and implement the patient's plan of care. Fnctions as a care manager coordinating the implementation of the care plan. Shares an advocacy role for patients and families with other members of the team. Develops and maintains collaborative relationships with other members of the IDG

20 Social Workers Provide conseling and spirital care to help patients and their families address their economic, psychosocial, and emotional needs. Skilled in active listening, the social workers take their lead from their clients, assessing the patient's and family's needs and preferences for care in an initial consltation and sbseqent reassessments Key goals are: Achieving a sense of control Relieving brden on family members Strengthening relationships with loved ones

21 Goals and Why Hospice, Why Now? Patients with terminal illness and their families often have no idea what to expect The nknown can elicit fear, anger and hopelessness Edcation on disease process, i.e. what to expect Nrses provide key practical advice and are the real experts here Spport for patient and families

22 Take a rational approach to medications Simplify medication regimen if possible Provide analgesia and anxiolytics that will provide comfort Risk vs. Benefit on all meds needed

23 Incentives for Discontining Medications Risk vs. benefit ratio increased for many medications at end of life Impact qality of life Less side effects, less pills, less administration brden, etc. Decrease medications cost Meet the expectation of CMS Non-hospice related meds not covered nder hospice benefit

24 CMS Gidance in 2014 As of Jly 2014 Part D Medicare plans reqired to reject drgs in 4 categories for hospice patients: 1. Analgesics 2. Antianxiety 3. Anti-naseants 4. Laxatives

25 Palliative Medications Relieve crrent symptoms of disease Provide comfort to the patient No intention of prolonging life No intention of promoting cre No intention of achieving long-term positive otcomes

26 Non-palliative medications Crative only Preventative or prophylaxis Associated with long-term therapetic otcome

27 Commonly discontined medications Statins Vitamins (i.e. horse pills) Cognitive Enhancing Agents (minimal expectation of benefit for FAST score 6 and no benefit with FAST score of 7) Aricept (Donepezil) Namenda (Memantine) Exelon (Rivastigmine) Reminyl (Galantamine) Warfarin and New oral anticoaglants: d/c when KPS, PPS <40%; indication for contining are when symptomatic or high risk for thromboembolism Apixaban (Eliqis) Dabigatran (Pradaxa) Edoxaban (Savaysa) Rivaroxaban (Xarelto)

28 Commonly tapered or discontined medications Antipsychotics Anti-hypertensive medications Diretics NSAIDS Diabetes meds (hyperglycemia often not symptomatic) slfonylreas especially and all other Redce inslin

29 JNC 8 Blood pressre gidelines For all patients age >60 Target BP is <150/90 For hospice patients there is no need to be this aggressive (nless patient symptomatic) Non-cardiac Hospice patient goal can be <180

30 Cost Benefit Analysis JAMA 2014; 312 (18): Conclsions and Relevance In this sample of Medicare fee-for-service beneficiaries with poor-prognosis cancer, those receiving hospice care vs not (control), had significantly lower rates of hospitalization, intensive care nit admission, and invasive procedres at the end of life, along with significantly lower total costs dring the last year of life.

31 Cost savings in last year of life The average costs of care for patients in their last year of life in the nonhospice grop was $71,517, compared to $62,819 for those enrolled in hospice; savings totaled close to $9,000. The stdy also revealed a hge disparity: 74 percent of patients in the nonhospice grop died in a hospital or nrsing home, compared to jst 14 percent of hospice patients. Median hospice stay was 11 days. Cost savings wold likely be mch greater if hospice started earlier

32 Case Stdy 84 year old female with end-stage Alzheimer's Having increased behaviors, loss of continence and overall decline over the last 3 months 82 year old hsband and their daghter becoming more overwhelmed with caregiving needs Weight 6 months ago was 140 and she now weighs 125 Minimally verbal Recent falls and now reqires 1-2 per assist with walking (doesn t nderstand how to se walker); has had chronic back pain de to DDD What are KPS, PPS and FAST?

33 KPS, PPS are 40%, FAST is 7C Can add Adlt Failre to Thrive as co-morbidity Reqires assist with all ADLs Sleeping 12 hors per night and naps 2-3 hors more per day BP 120/70 and plse 62 Has to strain to have BMs and goes every 2-3 days Has pset stomach after taking arthritis med

34 Medication Review Crrent meds: donepezil 10mg Atorvastatin 20mg daily Atenolol 25mg daily Ibprofen 600mg three times daily as needed Aspirin 81mg daily Sertraline 100mg daily what changes shold be made?

35 Discontine some and add some Stop donepezil (no benefit for FAST score of 7) Stop atorvastatin Stop Atenolol Stop ibprofen Stop aspirin Add hydrocodone 5/325 every 6 hors as needed Add lorazepam 0.5mg ½-1 tab every 6 hors as needed Add senna-s 2-3 caps at bedtime

36 Frther considerations Hospital bed for positioning and comfort Massage therapy for back pain

37 Hospice Services started Nrsing visits 1-2 times per week Social work and spirital care 1-2 times per month Nrses aide for weekly bath and 1-2 other times per week Volnteer for caregiver respite 2-4 hors per two days per week

38 Patient more comfortable Caregivers less stressed and less worried abot needing to send patient to a nrsing home Relieved to have nrse on call for qestions and medication management

39 Even in the dying process Osteopathic Principles The body is a nit, and the person represents a combination of body, mind and spirit. Strctre and fnction are reciprocally interrelated. And on a hospice note: stop aggressive treatments that do more harm than good. Involve the family and caregiving teams to help provide comfort and ease sffering

40 Thank yo very mch!