Objectives 2/11/2016 HOSPICE 101

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1 HOSPICE 101 Overview Hospice History and Statistics What is Hospice? Who qualifies for services? Levels of Service The Admission Process Why Not to Wait Objectives Understand how to determine hospice eligibility and general hospice guidelines Be able to identify medical diagnoses most often covered by hospice services Be able to identify performance scales and other assessment tools commonly utilized in hospice Know when to refer to hospice services 1

2 Where Did it Begin? first modern hospice in England first hospice in U.S. in Connecticut Congress includes a provision to create a Medicare hospice benefit What does it look like now? 6,100 hospice programs in U.S. About 99 hospice programs in South Carolina Over 1.6 million patients served in 2014 Hospice Statistics 2000: 4.2 million Americans age 85 or older 2050: 19 million Americans over 85 Increase on demand for palliative and end-of-life care 2

3 What is Hospice? Not a place but a concept of care Can be given anywhere home, nursing home, assisted living, hospital, hospice house, etc. For those with a terminal illness that no longer responds to cure-oriented treatments Hospice is the something more that can be done when there is no cure What is Hospice? Support program for the patient and family Pain and symptom management Emotional and spiritual support Teaches the family how to provide care What is Hospice? Regular visits from team during the week 24/7 on-call nursing services Focus on non-curative, comfort care Individualized plan of care Hospice does not hasten death or prolong life Hospice is about living life to the fullest with dignity and comfort. 3

4 How do you Qualify for Hospice? Certified by physician as terminally ill Prognosis of 6 months or less Includes cancer and non-cancer diagnoses Maximum hospice benefit through early referrals Determining Hospice Eligibility Would you be surprised if this patient were to die within the next six months? Has the patient experienced rapid decline evidenced by rapid loss of function, rapid weight loss, frequent ER or hospital visits, increased office visits, or significant lab or X- ray changes? Important Co-morbidities Cardiopulmonary Diseases: CHF, COPD, CAD, PVD, CVA Renal Disease: HTN, DM, vascular disease Liver Failure: Alcoholism, hepatitis Diabetes: HTN, obesity Chronic Degenerative Neurological Disease: Alzheimer s, Parkinson s, ALS, MS 4

5 General Guidelines Life-limiting condition (six months or less) Patient/family have elected to not seek aggressive treatment for disease process Patient s physician is in agreement with patient s desire for no further aggressive treatment Increasing ED visits, hospitalizations, and/or PCP office visits over the last 6 months Patient Needs Have the activities of daily living been affected? Does the patient now require assistance with bathing, dressing, feeding, transfers, toileting, and/or ambulating? Is the patient requiring increased recovery/rest time? Is the patient sleeping more? Weight Loss Is there unintentional weight loss of 10% or more over the last 6 months? Is the patient having dysphagia, choking, or poor oral intake? Is the patient having inadequate nutrition despite PEG or other tube feeding? 5

6 End-Stage Neurological Disease Includes, but not limited to, ALS, dementia, Parkinson s, and CVA Weight loss of 10% or more in the last 6 months or weight loss of 7.5% or more in the last 3 months despite adequate nutrition Current history of pulmonary aspiration without effective response to speech pathology intervention End-Stage Neurological Disease Critically impaired breathing capacity as evidenced by: significant dyspnea at rest, required supplemental oxygen at rest, and/or declines artificial ventilation Rapid decline as evidenced by: progression of normal to barely intelligible or unintelligible speech, progression from normal to pureed diet, development of decubitus ulcers, and/or recurrent aspiration pneumonia Cancer Disease with metastases to: bone, liver, brain, or other site Patient declines further disease-directed therapy 6

7 Cardiopulmonary Conditions End-Stage Cardiac Disease optimally treated with diuretics and vasodilators, NYHA Class IV (physical activity causes discomfort and symptoms present at rest), & angina at rest resistant to nitrate therapy or declines invasive procedures Other signs/symptoms to consider dependent/pitting edema, syncope, orthopnea, weakness, chest pain, EF 20% or < (if available), JVD, arrythmias, and cachexia Cardiopulmonary Conditions End-Stage Pulmonary Disease disabling dyspnea at rest, poor response to bronchodilators resulting in decreased functional capacity (bed to chair existence), increased incidence of respiratory infections during last 6 months, and/or hypoxemia at rest (SaO2 88% or < on room air) Other signs/symptoms to consider resting tachycardia, syncope, rales, EF 20% or < (if available), liver enlargement, cachexia, and dyspnea at rest HIV CD4+ count <25 cells/mcl or persistent (tested twice at least one month apart) viral load > 100,000 copies/ml along with systemic lymphoma, toxoplasmosis, renal failure without dialysis, unresponsive wasting (loss of 33% of lean body mass), CNS lymphoma, and/or Kaposi s sarcoma Other signs/symptoms to consider chronic/persistent diarrhea for 1 year, persistent serum albumin < 2.5 gm/dl, active substance abuse, CHF symptoms at rest, absence/resistance of antiretrovival, chemo or prophylactic HIV treatment 7

8 Liver Disease PT more than 5 sec or INR >1.5 and serum albumin <2.5 gm/dl Ascites, hepatic encephalopathy (decreased awareness, disturbed sleep, depressed, emotionally labile, somnolence, and/or slurred speech) Recurrent variceal bleeding despite therapy Other signs/symptoms to consider progressive malnutrition, muscle wasting, continued alcoholism, Hepatitis B and/or C infection, and/or may be on transplant list Renal Disease Discontinues or refuses dialysis Co-morbid conditions to consider cancer, advanced cardiac, liver, or lung disease, cachexia, GI bleeding, platelets < 25,000, GFR < 10 ml/min, and/or intractable fluid overload Medicare Medicaid VA Private Insurance Charity Care Who Pays for Hospice? 8

9 Karnofsky Performace Status Normal; no complaints; no evidence of disease Able to carry on normal activity; minor signs or symptoms of disease Normal activity with effort; some signs or symptoms of disease Cares for self; unable to carry on normal activity or to do active work Requires occasional assistance, but is able to care for most of their personal needs Requires considerable assistance and frequent medical care Disabled; requires special care and assistance Severely disabled; hospital admission is indicated although death not imminent Very sick; hospital admission necessary; active supportive treatment necessary Moribund; fatal processes progressing rapidly. 0 - Dead Karnofsky Performance Status Uses 10 point scale Most hospice appropriate patients fall in the 50 or < categories Other Functional Assessment Tools Palliative Performance Scale, FAST scale, ECOG performance status Mid-Arm Circumference 9

10 Hospice Team Medical Director Attending Physicians Registered Nurses Hospice Aides Chaplains Social Workers Volunteers Bereavement Levels of Service Routine Respite Crisis Care General Inpatient Care The Admission Process Anyone can make a referral to hospice We will come to their home and explain our services (free of charge) We will help contact their doctor to determine eligibility and obtain an order If they are eligible, a hospice nurse will enroll them into the program 10

11 Benefits of Earlier Hospice Care Stabilization of symptoms Decrease in ER and doctor s office visits Less caregiver stress and more time for education Some patients actually live longer and with greater quality of life Revocation and Discharge Can stop hospice anytime and seek curative treatment If patient gets better, we stop services Available again if needed 11