Neurological Conditions: Disease Trajectory and Hospice Eligibility

Transcription

1 Neurological Conditions: Disease Trajectory and Hospice Eligibility Terri L. Maxwell PhD, APRN VP, Strategic Initiatives Weatherbee Resources/HEN 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 common neurological conditions Identify secondary and co-morbid conditions commonly associated with neurological conditions Recognize the body structure(s) and body function(s) related to neurological conditions Recognize activity/participation and environmental components related to neurological conditions Describe clinical documentation that supports medical necessity and substantiates hospice eligibility for patients with neurological conditions 1

2 International Class of Function, Disability and Health (ICF) Structure Function Activity Participation Environment Hospice Eligibility for Neurological Diseases Identification and documentation of relevant secondary & co-morbid conditions, combined with specific structural/functional impairments and activity limitations associated with the neurological condition may support a prognosis of 6 months or less. 5 Neurological Conditions CVA/Stroke Parkinson s Disease ALS Huntingdon s chorea Coma, etc. 2

3 Stroke Stroke occurs when blood flow to the brain is disrupted. Lack of oxygen to the brain causes brain cells to die. Patients who do not die during the acute hospitalization tend to stabilize with supportive care. Continuous decline in clinical or functional status over time indicates poor prognosis. Types of Strokes Ischemic Stroke Thrombotic Caused by narrowing (occlusion) of blood vessel in the brain Most common type (60%) Associated with HTN and diabetes Embolic Embolus lodges in and occludes a cerebral artery Rapid occurrence with severe symptoms CVA Structure 9 3

4 Classification of Strokes Hemorrhagic Stroke 15% of all strokes Result from bleeding into the brain tissue itself from a ruptured vessel Intracerebral Prognosis poor (50% die w/in weeks) Associated with HTN Subarachnoid Bleeding into the cerebrospinal fluid-filled space usually due to rupture of cerebral aneurysm High morbidity/mortality CVA Structure 11 CVA Function Mental Functions Function of Digestive System Neuromusculoskeletal and movement related function Hemiplegia Weakness Dysphagia Lack of Coordination Seizures Depression, emotionally labile 12 4

5 CVA Function Mental Function Sensory Function Neuromusculoskeletal and movement related function Anxiety Numbness Falls Barely able to speak 13 Clinical Symptoms/Functional Changes Symptoms depend on area and amount of brain affected Impaired physical mobility Affect-emotional lability, depression Communication- aphasia/dysphagia Cognition/intellectual function/memory Impaired swallowing Visual field cut/sensory loss CVA Activity, Participation & Environmental Example Difficulty following simple directions Loss of fine motor skills Has a loving, caring wife that assists with care Unable to brush teeth 15 5

6 Parkinson s Disease Neuro-degenerative disorder with no known cause Clinical syndrome characterized by a variable combination of: Tremor Bradykinesia Rigidity Postural instability Parkinson s Disease Structure Occurs due to a progressive loss of dopamine containing neurons in the subsantianigradeep within the midbrain 17 Parkinson s Secondary Conditions Dementia Dysphagia Weight loss Autonomic dysfunction Dizziness, typically from orthostasis Sweating Sexual dysfunction Dystonia Drooling 6

7 Parkinson's Disease Function Mental Functions Cardiovascular Functions Neuromusculoskeletal and movement related function Digestive Function Dystonia Shuffled Gait Dysphagia Orthostatic hypotension Dementia 19 Parkinson's Disease Function Mental Function Sensory Function Neuromusculoskeletal and movement related function Flattening of affect Postural instability Delirium Bowel incontinence Digestive Function 20 Parkinson's Disease Function Mental Function Genitourinary Function Neuromusculoskeletal and movement related function Immunological System Function Garbled, mumbling speech Urinary tract infections Moody, periods of depression Seizures 21 7

8 Parkinson's Disease Activity, Participation & Environmental Example Patient has: Complete difficulty with mobility Complete difficulty with self care No family live in the area Dependent on SNF staff for total care Able to verbalize yes/no short sentences 22 Amyotrophic Lateral Sclerosis (ALS) Disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement (degenerative motor neuron disease) Upper (brain) and lower (spinal cord) neurons eventually die, ceasing to send messages to the muscles Muscles eventually weaken, atrophy, twitch and voluntary movement is lost Cognition, eyesight, and bladder and bowel control are not usually impaired ALS Structure 8

9 ALS Prevalence Usually occurs at random (genetic defect associated with 10% of cases) Life expectancy 3-5 yrs, but some pts live much longer Death usually a result of respiratory failure ALS Symptoms Early: Muscle stiffness/ weakness Slurred speech Difficulty swallowing Cramps Fasciculations Late: Progressive muscle atrophy/weakness Swallowing/chewing problems Respiratory difficulty Emotional lability ALS Secondary Conditions Weight loss Aspiration Pressure sores Pneumonia Pain Constipation Lung failure Drooling of secretions Symptoms of chronic hypoventilation (am headache, anorexia, wtloss, depression/anxiety, severe fatigue) 9

10 ALS Management Supportive care (interdisciplinary approach): Medical management Speech therapy Nutrition assessment/swallow evaluation PT/OT/Rehab Respiratory therapy/pulmonology Social Worker Home care/hospice Support groups Palliative care Hospice/Palliative Care Triggers for ALS The patient or family asks or opens the door for end-of-life information and/or interventions, or Severe psychological and/or social or spiritual distress or suffering, or Pain requiring opiates, or Dysphagia requiring feeding tube, or Dyspnea or symptoms of hypoventilation, forced vital capacity at 50% or less, or Loss of function in two body regions Reference: Promotingexcellence.org ALS Function Digestive Function Mental Function Voice & Speech Weight loss Difficulty with speech Constipation Inability to control secretions 10

11 ALS Activity, Participation & Environmental Example Moderate difficulty with communication Total self-care Has attentive family, very active with friends and family ALS support group visits regularly Has computer equipment to assist in communication Has lift installed through out home to assist with transferring pt Coma Definition Coma: Unarousableunresponsiveness in which the subjects lie with eyes closed. Unable to consciously speak, hear, feel or move. Causes include drug poisoning, stroke, oxygen deprivation due to cardiac arrest, etc. Glasgow Coma Scale-used to examine and determine the depth of coma, track patients progress, and predict outcome as best as possible. Coma Structure 11

12 Coma Prognosis Outcome depends on the cause, location, severity and extent of neurological damage. Most common cause of death is secondary infection such as pneumonia. Neurological Secondary and Co-morbid Conditions Secondary conditions Skin breakdown and decubitus ulcers Contractures Constipation associated with immobility Nutritional impairment/weight loss Pain Aspiration pneumonia and other infections Co-morbid conditions Document ways in which co-morbid conditions impact the terminal disease trajectory. Neuro Admission Documentation Answer the question: Why Hospice, Why Now? Decline in health and functional status in months preceding referral to hospice Changes in nutritional status and associated weight loss Changes in functional status (include, but don t limit to PPS or KPS) Respiratory status Cognitive status History of hospitalizations, ED visits, etc. Goals of care 12

13 Ongoing Documentation for Recertification Descriptions of: Declining functional status/disability Weight loss or indicators of such Respiratory status, aspiration, secretions, etc. Symptoms, including pain Secondary conditions-pressure ulcers, infections, emotional labiality, depression Medication changes Use of assistive devices Caregiver burden Documentation sample (admission) Allen, age 53 was diagnosed with ALS 16 mos ago after noticing difficulty lifting weights in the gym. His condition has progressed and he recently d/c d Rilutek. He now requires total assist to transfer from bed to w/c and is completely dependent in 5/6 ADLs. He is continent of urine/stool, but has bouts of severe constipation despite a bowel program. His speech is largely unintelligible, although his wife and son are able to understand some of what he says. He is learning to communicate with a computer-assisted device. Documentation sample (admission cont d) He is alert and oriented x 3, but has become anxious due to worsening difficulty breathing. He s lost 30 lbs (5 10, 158lbs) over the past 8 weeks. He tolerates his pureed diet poorly and in the past 3 weeks, is having frequent choking episodes. Over the past 2 weeks, he s become increasingly dyspneic at rest, RR 26. He sleeps 4/8 hours during the day and is awake frequently at night. He is married with 2 sons ages 19 & 21-both attending college. He refuses mechanical ventilation, but uses C-PAP at night. He does not want a PEG and has an advance directive requesting comfort measures only 13

14 Neurological Condition Documentation Example Ms. Thomas, age 86 was found by nursing home staff without a pulse or breathing. She was resuscitated and transferred to X medical center. It was not known how long Ms. Thomas was without oxygen. She was in the ICU for several weeks, but never regained consciousness. Her hospital course was complicated with repeated bouts of aspiration pneumonia, sepsis, and renal failure (Creatinine > 2.5 mg/dl). After meeting with the palliative care team, Ms. Thomas family requested comfort measures only and wanted her transferred back to the nursing home where she resided prior to this event. PEG feedings were d/c d. Co-morbids include HTN, previous MI, diabetes and dementia. Supporting Documentation example: Is this Patient Eligible? This is the 2 nd recertification for Mr. Johnson, age 69 who suffered an ischemic stroke 10 mos ago. He was transferred to Sunshine Nursing Home and referred to hospice. Mr. Johnson is receiving PEG feedings due to problems eating post CVA. His weight is 182 lbs, up 2 lbs in past month. He has a stage 1 decubitus ulcer on both heels, which are being treated with heel protectors and emollients. He has confusion at night, treated with quetiapine prn. No fever or infections since pre-hospice hospitalization. Wife visits daily. Conclusion Hospice eligibility and recertification for patient s with neurological conditions is based on the description of the effects of their condition on the structural, functional, activity, participation and environmental domains, plus documentation of secondary and comorbid conditions. 14

15 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 Weatherbee Resources & Hospice Education Network tmaxwell@weatherbeeresources.com info@hospiceonline.com 15