Hospice 101: A Primer for the PCP/Hospitalist John Thompson, II DO, DABFM, HMDC
Objectives: Understand the difference between Hospice and Palliative Medicine. Have a general understanding of hospice criteria for various disease states and when to refer to hospice. Review of commonly used pain medicines in hospice care. Introduction to prognostication. Review of Hospice levels of care.
Hospice To neither hasten nor delay an inevitable death. From our friends at Wikipedia: Hospice care is a type of care and philosophy of care that focuses on the palliation of a chronically ill, terminally ill or seriously ill patient's pain and symptoms, while attending to their emotional and spiritual needs. Patients not seeking/no longer seeking curative treatment. An interdisciplinary, not a multidisciplinary, approach involving Physicians, RNs, Social Workers, Chaplains, and Volunteers. Guidelines i.e. regulations are set by Medicare.
Hospice Is a home based program! Unless a patient has straight Medi-Cal or is VA affiliated hospice does not pay for care in a SNF (except Respite Care). It is NOT 24 hour care (with certain exceptions), but it IS 24/7 nursing availability. Is reimbursed on a per-diem/day rate model, so any treatments related to the terminal diagnosis come out of the hospice per diem bucket. Treatments that are not related to the terminal diagnosis are still covered by Medicare/insurance. All hospice expenses come out of that bucket; RN visits, Hospice Aides, Chaplain visits, meds, etc. Example: Patient on service for liver failure with comorbid COPD, we pay for lasix, aldactone, lactulose, and anything related to liver disease. Medicare pays for Combivent, Advair, etc.
Palliative Medicine An approach to medicine that focuses on relieving symptoms, not necessarily attempting to cure, the underlying disease process. NOT the same as Hospice! Many Palliative Care docs/clinics follow oncology, CHF, COPD, etc. patients that are seeking curative/life prolonging treatments.
Continuum of Care
Hospice Criteria Generally, life expectancy of 6 months or less. Guidelines are set by Medicare. Though the guidelines are set by CMS/Medicare, they are still generally guidelines and for the most part we have some latitude to use our clinical judgement. However, if the patient doesn t meet any specific disease criteria we as Medical Directors still need to make a convincing case that the life expectancy is 6 months or less.
Disease Specific Criteria Cancer - progressed despite treatment or metastatic at time of presentation and not, or no longer, seeking curative treatment. Dementia - What? No longer allowed (except specific diagnoses such as Alzheimer s, Lewey Body, Frontotemporal). Cerebrovascular Disease is our new Dementia &/or Debility and Decline.
Criteria - cont. Liver Disease, need criteria from 1 & 2: 1. INR >/=1.5 & </=Albumin 2.5. 2. Ascites refractory to treatment (or patient noncompliant), SBP, HRS, Hepatic encephalopathy refractory to treatment (or pt noncompliant), Recurrent variceal bleeding. Patients seeking liver transplant can be on hospice.
Criteria - cont. Renal Disease, need 1 AND 2 or 3: 1. Not seeking dialysis or transplant (or discontinuing dialysis). 2. Creatinine clearance <10mL/min (<15mL/min in diabetics) or <15mL/min (<20mL/min in diabetics) if pt has comorbid CHF. 3. Serum creatinine >8.0 mg/dl (>6.0 mg/dl in diabetics).
FAST Score
Criteria - cont. Alzheimer s Disease - FAST 7C with recent (last 12 months) sepsis, recurrent pneumonia/uti s, etc. or FAST worse than 7C. Parkinson s - Stage 5: Patients fall when standing or turning, falling or freezing when walking, hallucinations or delusions. ALS - significant breathing impairment and not using or going off of a vent, significant dysphagia and no artificial hydration/nutrition, etc. COPD/CHF - SOB at rest worse with minimal exertion creating a bed to chair existence, ie Class IV CHF.
Certification Initial certification can be done by a phone call. Requires a Certification of Terminal Illness (CTI) from a PCP and the Hospice Medical Director. If you are asked to follow a patient on hospice, it generally means that you are willing to remain the PCP for the patient and will continue to manage the nonhospice related issues (although we usually manage most issues on our hospice patients). It usually DOES NOT mean that you are managing the day to day aspects of the hospice patient. This can be anything from getting simple updates to taking the first call on pain issues. First 2 certification periods are for two 90 day periods (180 days).
Re-Certification Each recertification period is for 60 days. Each recertification after the initial two 90 day periods requires a face to face visit by a physician/np. Need to show decline in the patient. Commonly used symptoms of decline: Weight loss/muscle wasting (decrease in mid arm circumference). Decreased intake, usually measured objectively in cups per meal/day. Skin break down! Has the patient started to develop pressure sores, deep tissue injuries, etc? Are they healing, staying the same or getting worse? Increased sleeping/social withdrawal.
Prognostication Palliative Prognostic Score (PaP) - relies heavily on the clinical estimation of life expectancy, has been validated in adult and pediatric oncology populations, has been validated in oncology and non-oncology patients, and has been validated in large prospective studies. COPD - BODE score, based on BMI, exercise tolerance, FEV1, dyspnea rating. Alzheimer s Disease - Mortality Risk Index (validated for Nursing Home residents only).
Prognostication - cont. Congestive Heart Failure: NYHA Class II (dyspnea w/ normal activity): 1 year survival 90-95% Class III (dyspnea w/ mild activity): 1 year survival 85-90% Class IV (dyspnea at rest): 1 year survival 30-40%!
Pain Medications Morphine - Oral Morphine Equivalent (OME) the gold standard of pain meds, right? 1mg oral morphine = 1mg hydrocodone 1mg IV morphine = 3mg oral morphine/hydrocodone This means 2mg of IV morphine is the equivalent of 6mg of oral hydrocodone which means 2mg of IV morphine is roughly equivalent to taking a Vicodin after a procedure!
Pain Meds - cont. Equivalencies: 1.5 OME = 1mg oxycodone (Percocet) 5 OME = 1mg oral hydromorphone (Dilaudid) 25mcg/hr fentanyl patch = 30-90 OME/day 50mcg/hr = 91-150 OME/day 100mcg/hr = 211-270 OME/day 150mcg/hr = 331-390 OME/day, etc.
Pain Meds - cont. Methadone - dosing too complicated to get into here, but you do NOT need special licensing to prescribe it unless you are prescribing for maintenance therapy for opioid addiction! Start low and go slow; we commonly start patients out at 2.5mg one to two times a day, depending on their opioid usage and history. Affects QT interval, so caution in cardiac patients. Numerous potential drug-drug interactions. The only long acting opioid available in a liquid formulation.
Levels of Care Routine Home Care - what most folks are familiar with, a hospice patient at home, or a SNF, getting routine hospice care provided by the family (usually) with the support of hospice staff (CNA, LVN, RN, SW, Chaplain). $156.06/day. Continuous Care - for hospice patients in crisis (pain crisis, uncontrolled delirium, terminal agitation, etc) an RN for at least 8 out of 24 hours at the patients bedside in the home/snf to help control symptoms. Most expensive level of care: $910.78/day. Respite Care - usually provided in a SNF or inpatient hospice unit and provides for up to 5 days respite for care givers. $161.42/day.
Levels of Care - cont. General Inpatient - provided in a medicare approved inpatient hospice, hospital, or SNF and is for symptom management that requires 24 hour nursing attention/intervention that cannot be provided at a lower level of care. It is not a default status for patients that are actively dying, or for patients whose caregiving situation has broken down. $694.19/day. Per diem rates quoted are the national base rates for 2014, they are regionally adjusted based on the Wage Index for various geographic regions.
Take Home Points Medicare guidelines set the standard. Palliative Care and Hospice are not the same thing. Let your Palliative Care Team, if you have one, help you! If you don t have one, don t be afraid to start the conversation. If you are the one giving the bad news ask the patient and/or family what they heard regarding what was said not unusual for people to hear something different than what we think we said. There are validated models for prognostication for most disease states, but they are still only an estimate: Remember, People plan, and God laughs! Morphine, not quite as potent as we all think, but still the Gold Standard.
Take Home - cont. Please don t under medicate patients with legitimate sources of pain: I m not saying let s go back to pain is what the patient says it is, but my understanding is metastatic cancer can be painful and 2mg of IV morphine every 4 hours might be under treating. Hospice is a home based program, please don t tell patients they can go to a SNF with hospice without consulting your case managers/discharge planners. If you have a patient with class III-IV NYHA CHF, or O2 dependent COPD, consider a Palliative Care discussion/referral regarding goals of care. If they are truly class IV &/or O2 dependent you can refer for help with symptom management too!
Resources Oxford American Handbook of Hospice and Palliative Medicine and Supportive Care, 2nd Edition, Yennurajalingam & Bruera, Oxford University Press, 2016 Hospice Quickflips: A Guide for Hospice Clinicians, The Corridor Group, 2006/Reviewed 2015 Scottish Palliative Care Guidelines, www.palliativecareguidelines.scot.nhs.uk/ The American Academy of Hospice and Palliative Medicine, www.aahpm.org