Hospice Basics and Benefits

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Hospice Basics and Benefits
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Goal

• To educate nurses and other health care
  professionals about hospice basics and the
  benefits for the patient and family.

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Objectives

• Describe the history/philosophy of hospice
• List two or more criteria used to identify the
  hospice appropriate patient and some common
  diseases seen in end-of-life care
• Identify difference between curative and
  palliative care
• Explain Medicare Reimbursement for hospice
• Discuss the relevance of advance directives and
  DNR when discussing hospice services

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All of Us Will Die

• lt10 suddenly, unexpected event, heart attach
  (MI), accident, etc
• gt90 protracted life-threatening illness
• Predictable steady decline with a relatively
  short terminal phase (cancer).
• Slow decline punctuated by periodic crises (CHF,
  emphysema, Alzheimers)

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Dying in the 19th Century

• 3 of Americas population was gt65
• Life expectancy was 45-50 years
• Most people died at home

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Dying in the United States Today

• 13 of the population is gt 65 years
• Approximately 75 of Americans die in health care
  facilities
• 57 die in hospitals
• 17 die in long
• term care facilities

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Care at the End-of-Life

• Q Where would you prefer to receive medical
  care if you were terminally ill with a prognosis
  of 6 months or less?
• A 9 out of 10 respondents cite their home as
  the preferred site of care.

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History of Hospice

• Linguistic root words
• Hospital
• Hospitality
• Shelter
• Respite
• Caring
• A place of refuge and solace

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Hospice History U.K.

• 1905 St. Josephs Sisters of Charity in London
• 1967 St. Christophers in London
• You matter because you are you. You matter to
  the last moment of life, and we will do all we
  can, not only to help you die peacefully, but
  also to live until you die.
• -Cicely Saunders

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Hospice History U.S.

• 1969 Elizabeth Kubler-Ross On Death and Dying
• Brought death and dying into mainstream
• 1974 New Haven Hospice of Connecticut
• 1976 VITAS beginnings
• 1978 National Hospice Organization
• National Hospice Palliative Care Organization
  now
• Mission - to lead and mobilize social change for
  improved care at the end of life

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VITAS Beginnings

• Available for ALL in the location of their
  choice, 24 hours a day, 7 days a week, for
  whomever needs it regardless of race, religion,
  and/or inability to pay
• clients and families can and will teach us what
  they need and determine their plan of care
• The Interdisciplinary group provides care with
  the integration of medical, psychological and
  spiritual services
• Staff efforts at the bedside should be supported
  and coming to work should be a rewarding
  experience

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What is Palliative Care?

• The study and management of patients with
  active, progressive, far-advanced disease for
  whom the prognosis is limited and the focus of
  care is quality of life.

Oxfords Textbook of Palliative Medicine
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Palliative Care ...

• Affirms life
• Regards dying as a normal process
• Neither hastens nor postpones death
• Provides relief from pain and other symptoms
• Integrates the psychological spiritual aspects
  of care
• Provides support for patient and family

World Health Organization
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Curative vs. Palliative Care

• Curative
• Disease driven
• Doctor in charge
• Disease process is primary
• Few choices

• Palliative
• Symptom driven
• Patient is in charge
• Disease process is secondary to person
• Many choices
• Comfort quality of life

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Patient Appropriateness

• Life-limiting illness
• Medicare regulations
• Six months or less prognosis
• Two physicians
• Patient and/or family request

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Oncology (Cancer) Diagnoses

• Breast CA
• Bone CA
• Renal Cell CA
• Pancreatic CA
• Bladder CA
• Malignant Melanoma

• Lung CA
• Colon CA
• Advanced Prostate CA with metastasis
• Head Neck CA

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Non-Oncology Diagnoses

• End Stage
• Cardiac
• Pulmonary
• Alzheimers Disease
• Renal Disease
• Liver
• Stroke (Acute Chronic)
• ALS (Lou Gerhigs disease)
• Debility Unspecified
• AIDS

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Disease Progression

• Change or decline in performance status
• Loss of appetite
• Excessive weight loss
• Difficulty breathing
• Pain

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End of Life Symptoms

• Unrelieved pain
• Confusion
• Restlessness
• Weight loss
• Shortness of breath
• Disturbed bladder and bowel function
• Disrupted sleep
• Nausea and/or vomiting

Pain and symptom management is the first priority!
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End of Life Symptoms

• Psychosocial
• Depression
• Anxiety
• Ineffective coping and communication
• Life role transition
• Caregiver distress
• Spiritual
• Despair / hopelessness / isolation
• Powerlessness
• Loneliness
• Need for reconciliation

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After the End-of-Life

• Hospice provides care for the family after the
  patient dies via bereavement services
• For at least one year following a death, hospice
  provides
• Letters, cards
• Phone calls (visits)
• Bereavement support groups
• Annual memorial services
• Memory Bears

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Hospice Interdisciplinary Team

• Patient and Family
• Attending Physician
• Hospice Physician / Medical Director
• Registered Nurse
• Hospice Aide
• Social Worker
• Chaplain
• Volunteer

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Medicare Hospice Benefit

• Passed by Congress in 1982
• Covers 100 of costs related to the terminal
  diagnosis
• Includes HME
• Pharmacy
• Unlimited benefit periods
• Services are primarily reimbursed on a per diem
  basis

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Medicare Covered Services

• Skilled nursing services
• Physician visits
• Home health aide visits
• Volunteer services
• Medical social services
• Spiritual counseling
• Nutrition counseling
• Bereavement support for family

All services are provided based on the needs of
the patient and family!
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Four Levels of Hospice Care

1. Routine Home Care
2. Continuous Care
3. Inpatient Care
4. Respite Care

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Ethical Issues

• Ethics Committees
• Advance Directives
• Do Not Resuscitate Order (DNR)

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Advance Directives

• Includes living wills, durable power of attorney,
  and health care surrogacy
• Define the medical care a patient wants or does
  not want to receive if they become terminally ill
  and are mentally or physically unable to
  communicate their wishes
• In 1990, Congress enacted the Patient Self
  Determination Act all healthcare providers who
  receive Medicare and Medicaid funds must provide
  information regarding Advance Directives to
  patients admitted to their program

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Hospice Advance Directives

• Patients do not have to have advance directives
  in order to receive hospice care
• Hospice staff will discuss the importance of
  advance directives in preserving patient choice
• Hospice offers training on advance directives

Advance Directives Preserve Patient Choice!
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Do Not Resuscitate Orders (DNR)

• DNRs communicate a patients wishes regarding the
  use of cardio-pulmonary resuscitation
• Patients are not required to sign a DNR in order
  to elect or receive hospice care

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Partner with Hospice

• Benefit from hospices rich history
• Know criteria used to identify the hospice
  appropriate patient
• Ask could the patients quality of life be
  better served by palliative care vs. curative
  care?
• Medicare Hospice Benefit covers 100 of the costs
  related to the terminal diagnosis
• Hospice educates patients/families on advance
  directives and DNRs

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• You matter because you are you.
• You matter to the last moment of life,
• and we will do all we can,
• not only to help you die peacefully,
• but also to live until you die.
• Dame Cicely Saunders
• St. Christophers Hospice,
• London, England

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References

• Ferrell, B., Coyle, N. (2008). The Nature of
  Suffering and the Goals of Nursing. Oxford
  Oxford University Press.
• Ferrell, B., Coyle, N. (Eds.). (2010). Textbook
  of Palliative Nursing (3rd ed.). Oxford Oxford
  University Press.
• Kinzbrunner, B., Policzer, J. (Eds.). (2011).
  End-of-Life Care A Practical Guide (2nd ed.). New
  York McGraw Hill Medical
• Kuebler, K., Berry, P., Heidrich, D. (2002).
  End-of-Life-Care Clinical Practice Guidelines.
  Philadelphia Saunders.
• Matzo, M., Sherman, D. (Eds.). (2001).
  Palliative Care Nursing Quality care to the end
  of life. New York Springer Publishing Company.
• Office, E. P. (2010). End of Life Nursing
  Education Consortium. Paper presented at the
  ELNEC Train the Trainer, Washington DC.
• Organization, NHPCO. (2012). Hospice Information.
  Caring Connections Retrieved 01/03/2012, 2012,
  from http//www.nhpco.org/i4a/pages/index.cfm?page
  ID3254
• Puchalski, C., Ferrell, B. (2010). Making
  Health Care Whole Integrating Spirituality into
  Patient Care. West Conshohocken, PA Templeton
  Press.

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Hospice Basics and Benefits