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1 End Stage Liver Disease (ESLD) End Stage Renal Disease (ESRD) Disease Trajectory and Hospice Eligibility Terri Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources Inc. & Hospice Education Network Course Handouts & Post Test To download presentation handouts, click on the attachment icon Presenter 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. Learning Objectives: ESLD Understand the clinical course of End Stage Liver Disease (ESLD) Describe the prevalence of ESLD State symptoms experienced by patients with ESLD Describe the MELD prognostic tool Name the clinical data points necessary to substantiate hospice eligibility for patients with ESLD 1

2 End stage liver disease (ESLD): Background Irreversible condition- leads to complete failure of the liver Usually a consequence of chronic liver diseases Life expectancy is very low unless patient is a candidate for liver transplant Causes of ESLD Chronic Alcohol abuse Hepatitis B and C Cirrhosis Hemochromatosis Cancer Acute Acetaminophen (Tylenol) overdose Viruses- hepatitis A, B, and C (especially in children) Reactions to certain prescription and herbal medications. Symptoms Nausea Diarrhea Edema Jaundice Pruritus Epistaxis Easy bruising Abdominal pain Weakness/fatigue Weight loss and muscle wasting Confusion 2

3 Complications Ascites Frequent infections Variceal bleeding Splenomegaly- leading to decreased platelet count Encephalopathy Spontaneous bacterial peritonitis Hepatorenal syndrome Hepatopulmonary syndrome Hepatic hydrothorax/pleural effusions Hyponatremia Prognostic Tool: Model for End-Stage Liver Disease (MELD) Score is an estimate of the patient s mortality while on the transplant list Uses objective criteria to determine severity of illness (Serum Creatinine, bilirubin, INR) Lowest score- 6; highest- 40 Barriers to Hospice Referral Comprises approximately 2% of hospice admissions Lack of validated metrics to guide physician referral Delay in hospice referral/acceptance while awaiting transplant NHPCO Facts and Figures,

4 LCD Guidelines for Hospice Eligibility and Recertification for ESLD NGS LCD Number L25678 CGS LCD Number L32015 NHIC LCD Number L29881 Part II Non-disease Specific Guidelines Note: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II of the LCD Both A & B must be met: A. Impaired functional status- KPS <70 or PPS <70 B. Dependence on assistance for 2 or > ADLs C. Presence of co-morbidities that contribute to disease burden HF Diabetes Dementia, etc. Part III Disease-Specific Guideline: ESLD 1. The patient should show both a and b: a. Prothrombin time prolonged >5 seconds over control or International Normalized Ratio (INR) >1.5 b. Serum albumin <2.5gm/dl 4

5 Part III Disease-Specific Guideline: ESLD 2. ESLD is present and the patient shows at least 1 of the following: a) Ascites, refractory to treatment or patient noncompliant b) Spontaneous bacterial peritonitis c) Hepatorenal syndrome (elevated creatinine and BUN with oliguria (<400ml/day) and urine sodium concentration <10mEq/l) d) Hepatic encephalopathy, refractory to treatment or patient non-compliant e) Recurrent variceal bleeding despite intensive therapy Part III Disease-Specific Guideline: ESLD 3. Documentation of the following will support hospice eligibility a. Progressive malnutrition b. Muscle wasting with reduced strength and endurance c. Continued active alcoholism (>80gm ethanol/day) d. Hepatocellular carcinoma e. HBsAg (Hepatitis B) positivity f. Hepatitis C refractory to interferon treatment Assessing and Documenting Disease Burden in ESLD Labs- PT/INR and albumin Complications- encephalopathy, refractory ascites, recurrent variceal bleeding, etc. Severe impairment of ADLs, progressive weight loss, wasting, mental status changes, etc. 5

6 Supporting/Ongoing Documentation Changes in signs/symptoms Mental status changes- lethargy, confusion, coma Medication changes- addition/discontinuation/titration/route of administration, etc. Bleeding, nausea, etc. Increased service utilization Need for more frequent visits Greater involvement by members of IDT Caregiver burden Documentation example The patient has been increasingly confused the past hrs. Daughter reports being up most of the night with pt, who was repeatedly trying to climb out of bed. Pt refusing all po, including medications except for occasional ice chips. Appears more somnolent this am. He has 4 +LE edema, his abd girth is 64 (up 2 in past 2 weeks) with new redness on his sacral area. ESLD: Management Liver pain- NSAIDs, dexamethasone and opioids Nausea- antiemetics such as haloperidol Encephalopathy- protein and sodium restriction, bowel clearance with lactulose. Since hepatic encephalopathy is a terminal condition- treatment is usually focused on managing confusion, etc. 6

7 Conclusion ESLD usually results from chronic conditions such as cirrhosis or hepatitis B or C Hospice eligibility- based on PT/INR & albumin values, as well as a list of complications and underlying conditions Initial and ongoing comprehensive patient assessment with documentation is necessary for enrollment and recertification. Resources American Liver Foundation: American Association for the Study of Liver Diseases: Center for Health Statistics: OHIRendstageliverdisease pdf End Stage Renal Disease (ESRD) Disease Trajectory and Hospice Eligibility 7

8 Learning Objectives: ESRD Understand the clinical course of End Stage Renal Disease (ESRD) Identify secondary and comorbid conditions commonly associated with ESRD State symptoms experienced by patients with ESRD Explain end of life issues experienced by patients with ESRD and their caregivers Name the clinical data points necessary to substantiate hospice eligibility for patients with ESRD ESRD: Background ESRD results when kidney function declines to the point where it no longer can sustain life <10% of normal kidney function Usually follows long history of chronic kidney failure Causes of Renal Disease Diabetes and hypertension are the most common causes of ESRD African Americans are disproportionately affected 8

9 Associated Co-morbidities HTN (Note: HTN may be a co-morbid or related condition) Coronary artery disease CHF Peripheral vascular disease Osteoporosis Stages of Chronic Kidney Disease Stage Description GFR 1 Signs of mild kidney disease with nml or better GFR 2 Mild kidney disease with reduced GFR 3 Moderate chronic renal insufficiency 4 Severe chronic renal insufficiency > 90% 60-89% 30-59% 15-29% 5 End-stage renal failure > 15% National Kidney Foundation, 2002 Signs of ESRD Oliguria High BUN and serum Creatinine levels Anemia Fluid and electrolyte imbalances Hyperkalemia Hypophosphatemia Hypomagnesmia 9

10 Complications of ESRD Cardiovascular CHF CAD Increased risk of stroke and atherosclerosis HTN-causes kidney disease and kidney diseases causes HTN Pericarditis Increased risk of infections Osteoporosis/neuropathy Symptoms of ESRD Loss of appetite Nausea/Vomiting Diarrhea/Constipation Fatigue Weight loss Confusion Irritability Depression Generalized edema/anasarca Low urine output Generalized weakness Ecchymosis Pruritis Muscle cramps and twitches Shortness of breath Pain Final Stages of ESRD If untreated, accumulated waste products and fluid can result in: Coma Seizures Death Anuric post-dialysis patients die within days; those with minimal residual renal function may live weeks or even mos however, 6-month survival is rare 10

11 Symptom Pruritus Symptom management Treatment Non-pharmacologic approaches combined with diphenhydramine or benzodiazepines Pain/dyspnea Opioids (fentanyl and methadone recommended) Secretions Delirium Anticholinergic medications such as atropine drops Haloperidol (manages N/V as well) Hospice Care & ESRD 3.8% of hospice admissions* Patients electing to enroll in hospice usually are those who have d/c d or elected not to receive dialysis Those receiving care for condition not related to ESRD may receive covered services under both the ESRD benefit and hospice benefit; whereas hospices are financially responsible for dialysis related to the terminal diagnosis or related condition.** *NHPCO Facts and Figures, 2010 **CMS Pub Medicare Benefit Policy Manual, 2004 LCD Guidelines for Hospice Eligibility and Recertification for ESRD NGS LCD Number L25678 CGS LCD Number L32015 NHIC LCD Number L

12 Part II Non-disease Specific Guidelines Note: These guidelines are to be used in conjunction with the Non-disease specific baseline guidelines described in Part II of the LCD Both A & B must be met: A. Impaired functional status- KPS <70 or PPS <70 B. Dependence on assistance for 2 or > ADLs C. Presence of co-morbidities that contribute to disease burden HF Diabetes Dementia, etc. Part III Disease-Specific Guideline: ESRD 1. Not seeking dialysis or renal transplant, or discontinuing dialysis. 2. Creatinine clearance <10cc/min (<15cc/min for diabetics): or <15 cc/min (<20 cc/min for diabetics) with comorbidity of CHF 3. Serum Cr >8.0 mg/cl (>6.0mg/dl for diabetics) NOTE: 1 and either 2,3 or 4 should be present. #5- GFR lends supporting documentation Part III Disease-Specific Guideline: ESRD 4. Signs and symptoms of renal failure: Uremia Oliguria (<400 cc/24 hr) Intractable hyperkalcemia (>7.0) not responsive to treatment Uremic pericarditis Hepatorenal syndrome Intractable fluid overload, not responsive to treatment 5. Estimated GFR <10mi/min NOTE: 1 and either 2,3 or 4 should be present. #5- GFR lends supporting documentation 12

13 Assessing and Documenting Disease Burden in ESRD History of illness Decision to discontinue or to not seek dialysis Serum creatinine, estimated GFR, creatinine clearance Comorbid conditions Signs and symptoms Degree of impairment of ADLs Supporting/Ongoing Documentation for ESRD Increased caregiver stress/burden Increased service utilization Need for more frequent visits Greater involvement by members of IDT Supporting/Ongoing Documentation for ESRD Changes in signs/symptoms Altered mental status- lethargy, confusion Skin changes/edema/pressure ulcers Medication changes- addition/ discontinuation/titration/route of administration, etc. Dietary changes 13

14 Documentation example Patient is now completely bed bound and increasingly somnolent with more frequent episodes of confusion. Sleeping on avg 20/24 hrs per day. Po intake reduced due to severe lethargy and anorexia. Caregiver providing maximal assist with all ADLs and is upset re: pt s confusion. Conclusion Hospice eligibility for ESRD is based upon a decision to forego dialysis, measures of renal status and the presence of signs and symptoms of renal failure. Complications of ESRD need to be carefully considered when making related determinations. Initial and ongoing comprehensive patient assessment with documentation is necessary for enrollment and recertification. Resources American Kidney Fund: National Kidney Foundation: End stage renal disease Center (CMS): National Kidney Disease Education Center: National Kidney and Urologic Disease Information Clearing House (NKUDIC) 14

15 Course Handouts & 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 15