Lecture: Hospice Care Pallia ve Care. Meredith Aus n, DO Steven Dupuis, DO

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1 Lecture: Hospice Care Pallia ve Care Meredith Aus n, DO Steven Dupuis, DO

4 Palliative Care, What Family Practice Physicians Do Better Addressing the difference between hospice and palliative care, recognizing appropriate patients and exploring symptom management. Meredith E. Austin DO Integrated Healthcare Associates Saint Joseph Mercy Hospice NOTHING TO DISCLOSE How people die remains in the memory of those who live on. -Dame Cicely Saunders 1

5 Objectives Defining hospice services Update on Medicare guidelines Hospice by the numbers Identifying appropriate patients for hospice referral Update on acceptable primary terminal conditions Explore end of life symptom management What is Hospice? Comprehensive and coordinated palliative care that focuses on comfort, dignity and personal growth for patients and caregivers by encompassing biomedical, psychosocial and spiritual aspects of the dying experience. How I View Hospice Care Getting back to the root of what medical care was designed to accomplish. To provide patients and families, relief of suffering and supports throughout the dying experience to allow patients to die with dignity in the environment of their choosing. 2

6 NHPCO Hospice Facts and Figures million received hospice care in 2013 In 2013 Median length of service 18.5 days 34.5% of patients were on service 7 days or less. 5,800 hospices in operation in % non for profit 66% for profit Less than 5% government agency Insurance Benefit Covered under the hospital insurance program Medicare Part A, Medicaid and most private insurances Two certifying physicians Hospice Medical Director Attending Physician 6 months or less prognosis if the disease runs its natural course. Things to consider Diagnosis of terminal condition Other health conditions whether related or unrelated to terminal diagnosis Current clinically relevant information supporting all diagnoses 3

7 What does it cover? Medicare Benefit Policy Update 5/2014 Hospices are to provide all drugs and biologicals for the palliation and management of pain and symptoms of a patient s terminal condition and related conditions. A hospice may use chemotherapy, radiation and other modalities for palliative purposes if it is determined that these services are needed. Medicare services for a diagnosis unrelated to terminal condition remain available. Core Services Physician Services Nursing Services- available and or on call 24/7 Medical Social Services Counseling Bereavement Dietary Spiritual 4

8 Non-core Services PT, OT and Speech-language pathology Hospice Aide Services Homemaker Services Volunteers Medical Supplies Drug, biologicals, and durable medical equipment related to terminal illness and related conditions. 5

Case No. 1 85-year-old male with a past medical history of COPD, HTN and gout that presents to the ED with complaints of with fatigue, weight loss, SOB and back pain.

9 Case No year-old male with a past medical history of COPD, HTN and gout that presents to the ED with complaints of with fatigue, weight loss, SOB and back pain. Work-up revealed metastatic lung carcinoma. Patient and family decided not to pursue cancer directed treatments and wish to focus on comfort and enroll in hospice. 6

10 Your chances of avoiding the nursing home are directly related to the number of children you have, Atul Gawande Levels of Hospice Care Routine home care - where most hospice care is provided Continuous home care - provided during a period of crisis and primarily consists of nursing care Inpatient respite care - available for caregiver fatigue/burnout General inpatient - uncontrolled symptoms or care that cannot be provided in another setting 7

11 Appropriate Patients for Hospice Referrals Any patient with a terminal diagnosis that chooses palliative care. Patients with uncontrolled symptoms that are effecting quality of life. No longer acceptable principle hospice diagnoses Failure to Thrive Debility (the catch all diagnosis) Dementia in diseases classified elsewhere with behaviors Dementia in diseases classified elsewhere without behaviors Malaise and Fatigue

12 Common Hospice Diagnosis Primary Diagnosis Cancer Non-Cancer Diagnoses Alzheimer s disease Heart Disease Lung Disease Other Late Effect CVA Kidney Disease (ESRD) Liver Disease Non-ALS Motor Neuron Amyotrophic Lateral Sclerosis (ALS) HIV / AIDS Hospice Eligibility Section 322 of the Benefits Improvement and Protection Act of 2000 (BIPA), states that the hospice certification of terminal illness shall be based on the physician s or medical director s clinical judgment regarding the normal course of the individual s illness. 9

13 Case No. 2 Mrs. Smith is a 78 year old female that is seen in your office for weakness and 20# weight loss. She suffered a CVA 6 months ago that resulted in right hemiplegia. She is cared for by her elderly husband. She is maximum assist with transfers to wheelchair, dependent on all care needs and often coughs with eating. Hospice Diagnosis Primary condition Late effect of cerebral vascular accident Secondary and contributing condition Cerebral vascular disease Dysphagia Debility 10

14 End of life symptom management Pain Dyspnea Delirium Secretions Symptoms most feared at the end of life Opioid Selection Things to consider Type of pain- somatic, visceral, neuropathic History of opioid use- naïve or tolerant Allergy and intolerance Renal and hepatic function Route of administration 11

15 Renal Impairment Avoid- Morphine, Codeine, Demerol Use with caution- Hydromorphone, Oxycodone Safest option- Fentanyl, Methadone Hepatic Impairment- All opioids Opioid titration Mild to moderate pain % increase of total daily dosing Moderate to severe pain % increase of total daily dose Short acting opioids can be increased every 2-3 hours safely Long acting opioids can be titrated every 24 hours Transdermal Fentanyl and Methadone can be titrated every 72 hours 12

16 Dyspnea Dyspnea is the subjective sensation of being unable to breath and is experienced by more than 70% of patients who receive palliative care. Underlying causes of dyspnea should always be evaluated and addressed before starting palliative measures. It is multifactorial including Physiological Psychological Environmental Social Dyspnea Opioids- exact mechanism is unknown. Decreases air hunger by decreasing ventilatory response to decreased O2 and rising CO2 levels. Morphine is the most studied opioid (hydromorphone, fentanyl, oxycodone also effective) Naïve patient- 5mg Q2-3 hours PRN Tolerant patient- increase by 50% of current dose, consider long acting 13

17 Dyspnea Oxygen- most effective in setting of hypoxia Movement of air- electric fans Anxiolytics are most beneficial with opioids Lorazepam or haldol 0.5-1mg Q4 PRN Steroids-oral and inhaled Dexamethasone 4-24 mg PO Q a.m. Bronchodilators Energy conservation Positioning Delirium Prevalence Terminal cancer patients->75% Reversible episodes- 25% Last 48 hours of life->40% Definition Disturbances of consciousness with inability to focus, sustain or shift attention. Onset is sudden (hours to days), and fluctuates throughout day. 14

18 Types Hyperactive- hypervigilance, agitation, hallucinations, restlessness. Concerned for falls, aggressive behaviors, pulling at lines and foley Hypoactive slow psychomotor activity, lethargy, withdrawn. Risk of aspiration, mistaken for depression Mixed delirium- alternates between both. Terminal restlessness- agitated delirium in dying patient. Risk Factors Drugs opioids, anticholinergics sedatives corticosteriods antipsychotics/depressants Hypoxia Hypotension Infections Brain Tumor Electrolyte Imbalance 15

19 Treatment Is the delirium distressing to patient/family? Treat reversible causes Discontinue contributing medications Antibiotics- benefit v. burden Opioid rotation Non-pharmacological Quiet room Decrease stimulation Family at bedside Pharmacological Treatment Neuroleptics- first line therapy Haloperidol Gold standard for delirium Most cost effective Starting dose- 0.5mg Q4 PRN, PO, SL, SubQ Olanzapine Risperidone Quetiapine 16

20 Pharmacological Treatment Benzodiazepines Not a first line therapy, as could contribute to worsen delirium Use in addition to neuroleptics Low dose lorazepam 0.5-1mg Q6PRN, PO, SL, IV, and cannot be given Sub Q. Case No. 3 Patient is a 67 year old female with advanced pancreatic cancer. She is being cared for at home by her children. Pain is well managed with MSContin 30 mg BID and Morphine concentrate 10mg PO Q3 PRN, and dexamethasone 4mg PO Qdaily. In the last 24 hours she has been seeing and hearing her deceased parents, she is unable to get comfortable, picking at covers, and experiencing insomnia. 17

21 Terminal Secretions A result of accumulation of oropharyngeal and bronchial secretions. Strong indicator of impending death Terminal Secretions Educate, Educate, Educate Repositioning Avoid suction-unable to reach, distressing to pt Avoid hydration Anticholinergics Atropine 1% ophthalmic-sublingual Glycopyrrolate (Robinul)-sublingual or parenteral (doesn t cross blood brain barrier) Scopolamine-transdermal, parenteral 18

22 References 19

23 I am dying with the help of too many physicians Alexander the Great Palliative Care.. what FP s do best! Steven J Dupuis DO FPC-CAQHPM Trinity Health-Mercy Health Physician Partners Holland Home Palliative Care Faith Hospice 1

24 No disclosures/conflicts. NO Pharma $ were accepted or any Sales Reps injured to bring this presentation to Vegas Copresenting with recent GRAMEP HPM Fellowship Graduate Meredith Austin DO First DO HPM Fellowship being launched this year in Partnership between Faith Hospice, Metro Health and the Trillium PC Institute longitudinal Program Objectives.improve patient care! All diagnostic or therapeutic plans be made in terms of the sick person, not the disease. To maximize the patient s function, not necessarily the length of life. To minimize the suffering of the patient and family. -- Eric Cassell M.D. The Nature of Suffering 2

25 Short pre test Most people nearing the end of life are capable of making their own decisions about care. True False False Most people nearing the end of life are not physically, mentally, or cognitively able to make their own decisions about treatment. As a result, advance care planning is essential to ensure that people receive care that reflects their values, goals, and informed preferences 3

26 What is palliative care? A. Care that provides symptom relief and other supports for people with serious illness B. Another term for hospice C. The default care choice when it is no longer possible to cure an illness D. Care that comes only when people die About 1 in 4 Americans 65 and older dies in a hospital. One in three died at home. The majority of Americans express a preference for dying at home, which for some people may be an assisted living residence, nursing home, or skilled nursing facility. 4

27 A. Care that provides symptom relief and other supports for people with serious illness Palliative care is defined by the IOM committee as care that provides relief from pain and other symptoms, supports quality of life, and is focused on patients with serious advanced illness and their families. Palliative care begins early in the course of treatment for a serious illness Hospice is a type of palliative care. How many Americans age 65 and older die in the hospital? A. Nearly 1 out of 4 B. Nearly 1 out of 2 C. Nearly 2 out of 3 D. Nearly 9 out of 10 5

Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life www/iom.edu/endoflife Suggested citation: IOM (Institute of Medicine). 2014.

28 Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life www/iom.edu/endoflife Suggested citation: IOM (Institute of Medicine) Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press. Findings Care Delivery Multiple transitions between health care settings can fragment delivery of care and create burdens for patients and families Demand for family caregiving and the responsibilities of family caregivers are increasing Palliative care enhances quality of life, reflects patient choices, and supports families Widespread timely referral to palliative care appears slow 6

29 Summary Compared with standard oncology care, integrated palliative care led to: Improvements in QOL Lower rates of depression Less aggressive care at the end-of-life Greater documentation of resuscitation preferences Higher survival rates 7

30 End of life in America today Modern health care only a few cures live much longer with chronic illness dying process also prolonged... we will live longer lives, be better sustained by medical care, in return for which our deaths in old age are more likely to be drawn out and wild. -- Dan Callahan Current Realities Death less private due to medical supervision Patients dying in institutions have fewer sources of nonmedical support (family, church) Biomedical developments have made death more a matter of deliberate decision Dramatic breakthroughs retard and even reverse many conditions once regarded fatal Medical technology renders patients less able to communicate or direct course of treatment 8

31 Current Realities Palliative care postponed until death is imminent Prevalence of distressing symptoms substantial and underestimated Physiologic responses to symptom distress maladaptive Effective symptom control promotes recovery Belief that hospitals and its technologies have obligation to preserve life whenever possible regardless of human and economic costs Definitions Center to Advance Palliative Care: palliative care is an interdisciplinary specialty that aims to relieve suffering and improve quality of life for patients with advanced illness and their families. It is provided simultaneously with all other appropriate medical treatment. NQF: palliative care refers to patient-and familycentered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social and spiritual needs and facilitating patient autonomy, access to information and choice. Both definitions are independent of patient prognosis! 9

32 Trillium Institute definition Palliative Care focuses on the relief of suffering and improving the quality of life for patients with chronic or life threatening illnesses and offers support services to the patient s family. Patient s of any age and at any state of an advanced illness are eligible for palliative care Different from Hospice Palliative Medicine focuses on quality of life, control of pain and symptoms, and attention to the psychosocial and spiritual experiences of adapting to advanced illness. Hospice Care as defined by Meredith Austin DO. Is a FREE Medicare A Insurance Benefit when you are ready to give up the hospital..why would you not want to enroll? Terminal diagnosis Prognosis measured in months (as opposed to years) Completion, abandonment, or refusal of curative or remissive therapies 10

33 D i s e a s e M a n a g e m e n t / P a l l i a t i v e H e a l t h c a r e Interventions with Curative Intent* H o s p i c e Disease Modifying Interventions* Bereavement Palliative Interventions Consumer Education, Coaching, Empowerment Diagnosis of a serious or chronic condition Prognosis of foreseeable limited life expectancy or end-stage disease Death Adapted from: Fine PG, Davis M. Hospice: Comprehensive Care at the End of Life. Anesth Clinics North America, Philadelphia, Elsevier Saunders, Obstacles Professional culture valuing saving lives through advanced technology more highly than compassionate care at EOL Uncertainties in prognostication Inadequate training of caregivers in palliative medicine Fragmented, organ-oriented care 11

34 Holland Home Palliative Care Initiative Aggressive pain & symptom management Inpatient hospital consultations Home-based symptom management consultations with home care follow-up Skilled Care consultations Outpatient CA Clinic (Metro/WMHOS) Pediatric palliative care (DeVos) Why palliative care? Palliative care is patient centered care what do patients with serious illness need? Pain & symptom control Avoid inappropriate prolongation of the dying process Achieve a sense of control Relieve burdens on family Strengthen relationships with loved ones 12

35 Palliative Medicine Goals To facilitate communication between the healthcare team, patients, & family To relieve suffering by managing pain & symptoms To provide support for patient and family To provide advance care planning To facilitate bereavement support EPEC-O Self Study/free National Cancer Institute/ Robert Wood Johnson Foundation Education in Palliative and End-of-Life Care for Oncology (EPEC -O) is a comprehensive multimedia curriculum for health professionals caring for persons with cancer. Community Standard of Care This curriculum, divided into 3 plenary sessions and 15 content modules introduces the practicing health care provider to the knowledge and skills necessary to provide palliative interventions for patients with physical, psychosocial, and spiritual suffering associated with cancer. 13

36 Modifiable dimensions Spiritual, existential beliefs Loss, grief Symptoms Function Caregiving needs Fixed Characteristics Patient Psychological, cognitive symptoms End of life, dying Social issues 14

37 Process of providing care 15

HOSPICE My lecture outline

HOSPICE My lecture outline Objectives: o Describe a brief history of the development of hospice care o Describe the hospice philosophy of care o Describe the referral process o Describe hospice services o Describe reimbursement