Course Materials & Disclosure

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1 Pulmonary Disease: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources & Hospice Education Network Inc. Course Materials & Disclosure Course materials including handout(s) and conflict of interest disclosure statement are available to download with this course. This presentation is for educational and informational purposes only. It is not intended to provide legal, technical or other professional services or advice. Learning Objectives List the stages and understand the clinical course of pulmonary disease Identify secondary and comorbid conditions commonly associated with pulmonary disease Recognize the body structure(s) and body function(s) related to pulmonary disease Recognize activity/participation and environmental components related to pulmonary disease Describe clinical documentation that supports medical necessity and substantiates hospice eligibility for patients with pulmonary disease 1

2 Common Hospice Pulmonary Diagnoses ICD-9 Diagnosis COPD, Not Otherwise Specified Emphysema Obstructive Chronic Bronchitis Post Inflammatory Pulmonary Fibrosis Acute Respiratory Failure ICF Structure Function Activity Participation Environment Guidelines for Hospice Eligibility LCD for Cardiopulmonary Conditions (L31540) 2

3 Cardiopulmonary Conditions LCD Identify specific structural/functional impairments together with relevant limitations that serve as the basis for palliative care interventions and care planning. Body Structure The Lungs COPD Emphysema Alveoli are destroyed. Walls become inflamed & damaged. Elasticity is lost; pockets of dead air form. Airways narrow, air is trapped making breathing out more difficult. The ability to breathe is affected in the later stages of the disease. 9 3

4 COPD Bronchitis Bronchi (the main air passages to the lungs) become inflamed, usually as a result of viral or bacterial infection. Symptoms include coughing, shortness of breath, wheezing, and fatigue. 10 Restrictive Pulmonary Disease Results from scarring or thickening of lung tissue. Lungs unable to expand patient unable to breathe in. Symptoms include: Shortness of breath Chronic dry cough Fatigue Anorexia, weight loss 11 Secondary Conditions associated with Pulmonary Fibrosis Hypoxia can lead to pulmonary hypertension, which can lead to right sided heart failure. Pulmonary fibrosis increases the risk of pulmonary embolism. 4

5 Focus on COPD Chronic Obstructive Pulmonary Disease (COPD) Respiratory disorder characterized by chronic airway obstruction and lung hyperinflation 3rd leading cause of death in the US More women than men die of COPD 8.3% of hospice admissions (NHPCO Facts and Figures, 2012) Key Attributes of COPD 1. Airway obstruction 2. Not fully reversible 3. Progressive disease that generally worsens over time, even with treatment 4. Abnormal inflammatory response Celli BR et al. Eur Respir J. 2004;23:

6 Factors Determining COPD Severity Degree of symptoms Frequency and severity of exacerbations Presence of comorbidities that can lead to complications General health status Number of medications needed to manage disease Severity of spirometric abnormality/airflow limitation COPD Severity Severity of airflow FEV1 % Predicted obstruction Mild 50-80% Moderate 30-40% Severe <30% Spirometry is the gold standard for diagnosing COPD; severity is measured by FEV 1 Spirometry: Normal vs. COPD 6

7 Natural History of COPD FEV 1 <70- dyspnea with exercise FEV 1 <45- Exacerbations/hospitalizatio ns/dyspnea with ADLs FEV 1 <30- Systemic effects/dyspnea at rest/respiratory failure COPD and Co-morbids Common co-morbids: Cardiovascular disease Lung cancer Osteoporosis Musculoskeletal disorders Depression/anxiety Obesity/type II diabetes Functional Impairments in Pulmonary Disease Cough and abnormal breath sounds Fatigue, weakness Loss of appetite Shortness of breath following activity or lying down Swollen feet and ankles Weight loss Shortness of breath, dizziness or a choking sensation, accompanying chest pain Waking up from sleep due to shortness of breath when lying down (Orthopnea) 21 7

8 Systemic Effects of COPD Peptic ulceration Lung infections/lung cancer Weight loss/muscle wasting and weakness Hypoxemia and rising CO2 levels Pulmonary hypertension that may progress to right ventricular hypertrophy and cor pulmonale (right-sided heart failure) Osteoporosis Depression Acute COPD Exacerbation Definition: Sustained worsening of symptoms from patient s usual condition; acute in onset Symptoms Increased shortness of breath Increased sputum production and/or increase in purulence Increase cough Increased wheeze/chest tightness Decreased exercise tolerance Increased fatigue Altered mental status NICE GUIDELINES 2004 Therapy at Each Stage of COPD I: Mild II: Moderate III: Severe IV: Very Severe FEV 1 /FVC < 70% FEV 1 > 80% predicted FEV 1 /FVC < 70% 50% < FEV 1 < 80% predicted FEV 1 /FVC < 70% 30% < FEV 1 < 50% predicted FEV 1 /FVC < 70% FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Active reduction of risk factor(s); influenza vaccination Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Adapted from GOLD Guidelines. 1&intId=989 Add long term oxygen if chronic respiratory failure. Consider surgical treatments 8

9 Management of Stage IV: Very Severe COPD Characteristics Treatment FEV 1 /FVC < 70% FEV 1 < 30% predicted or FEV 1 < 50% predicted plus chronic respiratory failure Adapted from GOLD Guidelines, 2007 Recommended Short-acting bronchodilator as needed Regular treatment with one or more LA bronchodilators Inhaled glucocorticosteroids if repeated exacerbations Treat complications Rehabilitation Long-term 02 therapy if respiratory failure Consider surgical options Advanced COPD Management Long-acting and short-acting bronchodilators (albuterol) Anticholinergics (ipatropium bromide or tiotropium) Methylxanthines (theophylline) Combination inhaled therapies (formoterol/budesonide) Inhaled corticosteroids- note: long term oral steroids are not recommended however, 7-10 day course of prednisone may be helpful for exacerbations Adapted from GOLD Standards, 2007 Management of Advanced COPD (cont d) Antibiotics reserved to treat infections; do not use prophylactically Opioids oral and parenteral (not nebulized) to treat dyspnea Anxiolytics helpful in managing anxiety associated with dyspnea Oxygen therapy should be worn 15 hrs or > per day for greatest benefit 9

10 End of Life Issues Prognosis difficult to predict Frequent exacerbations requiring trips to the ED and/or hospitalizations Patients/family members frequently do not comprehend the terminal nature of the illness Lack of communication and advanced care planning Isolation/depression/anxiety Signs that Patient Requires Palliative Care FEV1 < 30% predicted History of 2 or more exacerbations in past year Frequent hospitalizations Progressive shortening of intervals between admissions Limited improvement after hospitalization Supporting Indicators Declining functional status/homebound Presence of comorbidities such as heart failure or diabetes On maximum therapy and dependence on oxygen Disabling dyspnea at rest. 10

11 Establishing, Evaluating, and Explaining Eligibility Based upon Burden of Illness in COPD Assessing and Documenting Disease Burden in COPD Sustained tachypnea (RR>30 breaths/min) Sustained tachycardia (RR>100 beats/min) O2 saturation <88% on room air or patient s usual supplemental oxygen Hypotension <100mm Hg or 20% lower than patient s usual Severe impairment of ADLs Assessing and Documenting Disease Burden in COPD Inability to speak in full sentences Sustained use of accessory muscles of respiration at rest Decreased ability to eat or sleep due to respiratory distress Repeated lung infections/courses of antibiotic therapy Hemoptysis/increased sputum production/cough 11

12 Assessing and Documenting Disease Burden in COPD Sustained increase in patient s usual degree of dyspnea Medication changesaddition or titration of opioids, anxiolytics, etc Altered mental statuslethargy, confusion Increased caregiver stress/burden Activities and Participation Learning & applying knowledge General tasks and demands Communication Mobility Self-care Domestic life Interpersonal interactions and relationships Major life areas Community, social & civic life 35 ADL Documentation Describe: How much caregiver support? None Minimal Moderate Total Time to completion of tasks 12

13 Environmental Factors Products and technology Natural environment and human-made changes to environment Support and relationships Attitudes Services, systems and policies 37 Case Example: Pulmonary Disease Referral #1: COPD Mr. Smith Age: 76 DX: COPD Residence: Home PCG: Wife PTA: 56 yr smoking history; lbs, BMI 17.7% Secondary conditions: dyspnea, cough, cachexia Co-morbid condition: hypertension 13

14 Measurable Data Points Pt: Mr. Smith DX: COPD SOC: 9/20/12 MEASURE PTA 9/20/12 Weight / BMI (5 9 ) / 17.7% KPS/PPS - 50% NYHA or FAST - - ADL Dependency - Amb, transfer, dressing and bathing Skin - - Infection Pneumonia - Oxygen PRN 3L cont / 90% Admission Note S Pt reports, I can t do anything anymore and I m totally exhausted all of the time. I can t catch my breath, even when I m sitting doing nothing. O Using accessory muscles & purse-lipped breathing; push of speech noted; rest; amb X 50 feet w/o rest 2 months ago; now rests 5-10 min after only 10 feet; uses W/C with PCG assist to maneuver in house (too weak to self-propel); 3L via NC; sat = 88% RA Admission Note, Cont d. Admitted with COPD Structural and functional limitations: Impaired respiratory function: dyspnea at rest, push of speech, purse-lipped breathing Oxygen dependent; O2 sat 88% KPS 50 & 4/6 ADL dependency Impaired mobility Weight loss 14

15 Body Function Dyspnea with activity Fatigue/wea kness ICF Domains COPD Body Structure Lungs Activity Impairment Participation Impairment Marked limitation Essentially of physical homebound activity, unable to propel wheelchair Dependent with all ADLs Loss of interest in leisure activities r/t fatigue Environmental Factors Handicap accessible BR- Bedside commode, wc, O2 equipment Attentive grandson Favorite dog Wheezing SOB inhibits meaningful interactions Dyspnea with conversations 24 hr PCG Bipap machine/ nebulizers Admission Note, Cont d. Secondary conditions: Pneumonia (onset, type & treatment) Extreme fatigue (AEB ) Productive cough (describe cough, treatment, response, etc.) Dyspnea with poor response to medication (describe) Oxygen-dependent (flow, pulse ox, etc.) Admission Note, Cont d. PMH: Increasing physician/er visits and hospitalization for recurrent infections Pneumonia w/respiratory failure (6/28/12) Supporting documentation: unintentional >10% weight loss over past 6 mos. Fully meets Cardiopulmonary LCD guideline 15

16 COPD Recertification Documentation Example Patient is now completely bed-bound and having new episodes of urinary incontinence. Caregiver providing maximal assist with all ADLs. Pt now severely dyspneic with minimal activity, including trying to speak. Sleeping on avg 18/24 hrs per day. PO intake reduced due to coughing/choking episodes. Using MSO4 q 4 ATC with moderate relief. Conclusion COPD is the 4 th leading non-cancer diagnosis in hospice Although irreversible and progressive, COPD prognosis is difficult to predict Hospice eligibility and recertification is based on the description of effects of COPD on the structural, functional, activity, participation and environmental domains, plus documentation of secondary and comorbid conditions. References 1. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2007) Poole, PJ, Veale, AG, Black, PN. Am J Respir Crit Care Med 1998: 157: International Classification of Functioning, Disability and Health; World Health Organization, NHPCO Facts and Figures, Nov

17 Course Evaluation & Post- Test Thank you for viewing this course on the Hospice Education Network. To conclude this course and to obtain a certificate of completion, you must finish the evaluation and post-test. Thank You! Terri Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Inc. & Hospice Education Network tmaxwell@weatherbeeresources.com 17