HOSPICE PHYSICIAN CHALLENGES October 2017 Panel Presentation Mimi Pattison, MD Hope Wechkin, MD Patrick Waber, MD Wayne Kohan, MD Finding the Right Hospice Diagnosis For the following cases, please consider the following questions: 1. Is the patient medically eligible for hospice? 2. If so, what is the most appropriate hospice diagnosis? Case 1 Rose B. is a 100 yo widowed female who lives in the house in which she was born with her daughter, her granddaughter, and two great grandchildren. Her daughter calls hospice intake on Monday morning to request assessment for hospice services. She reports that Rose last saw her primary care physician 6 months ago for a refill on her Lisinopril, which is her only medication other than acetaminophen. She has had no hospitalizations and no recent visits to the emergency department. Her only medical problems are hypertension and mild-tomoderate DJD. Her baseline BMI is 21, and she has enjoyed excellent health until quite recently. She is cognitively intact. Nine days ago Rose presided over a dinner for dozens of friends and family members to celebrate her one hundredth birthday. Several days after the party, she slept till 10 AM, which she d never done before. The next day she did not get out of bed. Since then Rose has been increasingly somnolent, sleeping approximately 20 hours per day. She s had small meals and some hydration when awake. On exam she is sleepy but arousable and neurologically intact. She endorses moderate pain that is greater than her baseline. Her family members are quite worried about her, as they say that this is completely unlike her. Rose herself reassures them and states that she is "ready to go." Family is anxious to receive hospice support. Hospice Physician Challenges Page 1
Case 2 Ruby S. is an 86 year old female with a distant history of breast cancer who recently presented to her physician with dyspnea and weight loss. She has no history of tobacco exposure. Her BMI is now 16. A chest x ray revealed a large left-sided lung mass. She has refused all further diagnostic testing and desires comfort care only. On exam, she is weak, mildly confused, and has decreased breath sounds over the left lower lung field. Case 3 Gerald L. is an 83 year old male with a medical history significant only for asthma who was found down in his home. He was taken to the ED, where it was noted that he had a POLST indicating a preference for DNR status and comfort care only. On exam he was nonresponsive and tachypneic with rhonchorous breathing. His son desired comfort care only. Case 4 Ralph G. is a 79 year old male with what is described in his medical record as end-stage dementia. He has a BMI of 24, and is non-ambulatory secondary to bilateral severe hip DJD. He is able to speak about 10 words, and recognizes his family intermittently. He has a stage III heel ulcer, and history of Parkinson s disease. Most recent serum albumin done 3 months ago was 3.2. He has refused to eat or drink for the past four days. Death with Dignity-A Case that did not go as Planned Case 5 54 yo male with stomach cancer admitted to hospice 1 week ago. Had been seen by primary RN one time. Wife and caregiver former ED RN. Lived in their own home that he built. No children. Patients Mother involved in care and lives close by. Week-end call to triage by wife requesting ED strength GI cocktail for heartburn. MD was called and asked for more information. Wife insisting she knew what he needed. Further review of chart not easily accessible initially revealed that patient had completed T-spine radiation 8 days ago. Had been on steroids for inflammation and PPI, both of which patient had been discontinued. MD informed nurse that this was mostly likely radiation esophagitis and not heartburn. Wife informed. Visit done to the home. Pain meds adjusted, PPI re-started, but concern expressed for adequate pain management and offered transfer to Hospice House Hospice Physician Challenges Page 2
for management. Adamantly refused transfer, wanting to die in the home he built. Wife mentioned briefly that patient at one time explored Death with Dignity option. MD informed of this. Thought at this stage with current symptoms he would be unable to take the med. Next morning call to wife reported patient not responding and seemed to be having pain. Nurse visited and was informed that the evening before, after having increasing pain and a tarry stool he decided to take the DWD meds as he was afraid it was his last opportunity. It was now 14 hours after the ingestion. He was unresponsive and grimacing with turns. Wife insisting on liquid Morphine for pain as patient was becoming somewhat more responsive. Nurse informed not to discuss that he took the meds did not want Mother to know. MD called for orders. What to do about ongoing care when safety a big concern? Case 6 55 yo male with progressive neurological disorder has been on your hospice for 6 weeks. He recently came out of an in-patient visit for pain management and is on a Fentanyl infusion for his pain. He was miserable in the unit as he could not smoke. He lives alone in a small home on neighbor s property. They are not family and not involved as caregivers but are friendly neighbors. To access his home there are 25 steps down to his residence. His functional status varies day to day. Some days he is able to get up and walk around, other days chair or bedbound. He has caregivers 4 hours a day. He has adequate funding for additional care giving but refuses. He is able to eat some and has a PEG tube mostly for meds specifically neuropathic pain meds. Last week the RN found him sitting in chair-no caregiver for 2 days and had not been able to administer his own meds. Does not have the manual dexterity. He was in a pain crisis. Refused to have an adjustment in his infusion. Had some bolus dosing and meds and the crisis resolved. He is a very high fall risk and the property he walks around on in rocky and not level. He refuses to use any device to help him ambulate. Hospice Physician Challenges Page 3
What is role of the attending physician? Case 7 62 yo female on service for metastatic breast cancer. PPS 40%. Lives with family who provide 24 hours care. History of drug and substance use disorder. On high dose opioid infusion and multiple adjuvant meds. Currently pain is controlled and no concerning behaviors. Does want to be followed by her oncology attending. Primary care physician agrees to follow her as long as she can still come to the office and he does not have to write for opioids or the other hospice meds. GIP Eligibility Case 8 85 yo male admitted to Hospice House from local hospital. He was hospitalized with increasing abdominal pain and confusion. He was found to have a pancreas mass with mets to the liver. Family declined further workup. PMHx is remarkable for DM, CHF, CAD and dementia FAST 5. During his hospital stay he had problems with nausea, pain control and agitation/restlessness. He required a sitter 1:1 while in the hospital. His medications on discharge to HH are risperidone 0.25mg q12 prn agitation, fentanyl TD patch at 12mcg/hr and morphine 1mg IV q6 hours prn. He has received no prn medications for the past 36 hours. On arrival to HH, he is confused, restless and agitated, attempting to get out of bed, uncooperative, unable to answer questions, grimacing at times, tachycardic, tachypneic, large amount of ascites. Poor swallow. Last BM not recorded, he had Foley in hospital but pulled it out himself two days ago, incontinent of bloody urine since then, amount of UO unknown. Over next two days, treated with frequent prn dosing of haloperidol and morphine, fentanyl titrated up. He is less anxious and restless, still confused. On routine haloperidol 5mg q8 and fentanyl at 50mcg/hr. Receiving about 3 doses of morphine for breakthrough pain and 1-2 extra doses of haloperidol for breakthrough restlessness daily. No med changes for past 24 hours. Family is unable to care for him due to his current medical condition. Three days later he is obtunded, unable to swallow. Fentanyl TD dose remains the same. Haloperidol discontinued due to poor swallow. Needs frequent turning and changing of bedsheets. Appears to be actively dying. Hospice Physician Challenges Page 4
MEDICATION COVERAGE FOR THE COMPLEX PATIENT Case 9 WHAT WOULD WE COVER? THE PATIENT, J.T. 69-year-old male Hospice Diagnosis of Lung cancer with brain and bone metastases COPD CAD Hypertension Seizure Disorder Insulin-Requiring Diabetes Mellitus Diastolic Heart Failure Hypothyroidism Bipolar Disorder Treatment to date included 3 rounds of Chemotherapy and Radiation to lung, brain and bone. He has had disease progression and has elected hospice. MEDICATIONS ON ADMISSION Morphine ER 30 mg po bid Morphine IR 15-30 mg po q 4 hours prn pain or dyspnea Dexamethasone 2 mg po tid Albuterol MDI 2 puffs inhaled q 4 hours prn dyspnea Symbicort 160mcg/4.5mcg 2 puffs inhaled bid Spiriva Respimat 2 puffs inhaled once daily Atorvastatin 80 mg po daily Fish Oil 2000 mg po daily Carvedilol 6.25 mg po bid Amlodipine 5 mg po daily Losartan 25 mg po daily Levetiracetam 500 mg po bid Divalproex Sodium 250 mg po tid Insulin Glargine 20 units sub q in evening Insulin Aspart 5-10 units sub q with each meal Levothyroxine 0.125 mg po daily Lorazepam 1 mg po tid prn anxiety Vitamin D3 2000 IU po daily Glucosamine HCl 1500 mg po daily Aspirin 81 mg po daily Clopidogrel 75 mg po daily NTG 0.4 mg SL q 5 minutes prn chest pain CBD Candy 10 mg po q 4 hours prn pain or anxiety Hospice Physician Challenges Page 5
THE CONDITIONS OF PARTICIPATION (CMS Rev. 69, Issued: 12-15-10, Effective: 10-01-10, Implementation: 10-01-10) 418.106 - Medical supplies and appliances, as described in 410.36 of this chapter; durable medical equipment, as described in 410.38 of this chapter; and drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, must be provided by the hospice while the patient is under hospice care TERMINAL DIAGNOSIS and RELATED CONDITIONS Terminal Diagnosis: - Metastatic Lung Cancer Related Conditions: -? Your Thoughts? MEDICATIONS COVERED? Morphine ER 30 mg po bid Morphine IR 15-30 mg po q 4 hours prn pain or dyspnea Dexamethasone 2 mg po tid Albuterol MDI 2 puffs inhaled q 4 hours prn dyspnea Symbicort 160mcg/4.5mcg 2 puffs inhaled bid Spiriva Respimat 2 puffs inhaled once daily Atorvastatin 80 mg po daily Fish Oil 2000 mg po daily Carvedilol 6.25 mg po bid Amlodipine 5 mg po daily Losartan 25 mg po daily Levetiracetam 500 mg po bid Divalproex Sodium 250 mg po tid Insulin Glargine 20 units sub q in evening Insulin Aspart 5-10 units sub q with each meal Levothyroxine 0.125 mg po daily Lorazepam 1 mg po tid prn anxiety Vitamin D3 2000 IU po daily Glucosamine HCl 1500 mg po daily Aspirin 81 mg po daily Clopidogrel 75 mg po daily CBD Candy 10 mg po q 4 hours prn pain or anxiety Hospice Physician Challenges Page 6