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Pulmonary Disease:Disease Trajectory and Hospice
Eligibility
Terri L. Maxwell PhD, APRN
VP, Strategic Initiatives
Weatherbee Resources &
Hospice Education Network Inc.
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
pulmonary disease
� Identify “secondary” and “comorbid” conditions
commonly associated with pulmonary disease� Recognize the body structure(s) and body function(s)
related to pulmonary disease
� Recognize activity/participation and environmental components related to pulmonary disease
� Describe clinical documentation that supports medical
necessity and substantiates hospice eligibility for
patients with pulmonary disease
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
2
Common Hospice Pulmonary
Diagnoses
ICD-9 Diagnosis
496.0 COPD, Not Otherwise
Specified
492.0 Emphysema
491.21 Obstructive Chronic
Bronchitis
515.0 Post Inflammatory
Pulmonary Fibrosis
518.8 Acute Respiratory Failure
ICF
Structure Function
Activity Participation
Environment
Guidelines for Hospice
Eligibility
LCD for Cardiopulmonary Conditions
(L31540)
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
3
Cardiopulmonary Conditions LCD
� Identify specific structural/functional
impairments together with relevant
limitations that serve as the basis for
palliative care interventions and care
planning.
Body Structure – The Lungs
COPD
Emphysema
� Alveoli are destroyed. Walls become
inflamed & damaged.
� Elasticity is lost; pockets of dead air form.
� Airways narrow, air is trapped making
breathing out more difficult.
� The ability to breathe is affected in the
later stages of the disease.
9
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COPD
Bronchitis
� Bronchi (the main air passages to the lungs) become inflamed, usually as a result of viral or bacterial infection.
� Symptoms include coughing, shortness of breath, wheezing, and fatigue.
10
Restrictive Pulmonary Disease
� Results from scarring or thickening of lung tissue. Lungs unable to expand – patient unable to breathe in.
� Symptoms include:
� Shortness of breath
� Chronic dry cough
� Fatigue
� Anorexia, weight loss
11
Secondary Conditions associated with
Pulmonary Fibrosis
� Hypoxia can lead to pulmonary
hypertension, which can lead to right
sided heart failure.
� Pulmonary fibrosis increases the risk of
pulmonary embolism.
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
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Focus on COPD
Chronic Obstructive Pulmonary
Disease (COPD)
� Respiratory disorder characterized by
chronic airway obstruction and lung
hyperinflation
� 3rd leading cause of death in the US
�More women than men die of COPD
� 8.3% of hospice admissions (NHPCO
Facts and Figures, 2012)
Key Attributes of COPD
1. Airway obstruction
2. Not fully reversible
3. Progressive disease that generally
worsens over time, even with treatment
4. Abnormal inflammatory response
Celli BR et al. Eur Respir J. 2004;23:932-946.
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
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Factors Determining
COPD Severity
� Degree of symptoms
� Frequency and severity of exacerbations
� Presence of co-morbidities that can lead to complications
� General health status
� Number of medications needed to manage disease
� Severity of spirometric abnormality/airflow limitation
COPD Severity
Severity of airflow
obstruction
FEV1 % Predicted
Mild 50-80%
Moderate 30-40%
Severe <30%
Spirometry is the gold standard for
diagnosing COPD; severity is
measured by FEV1
Spirometry:
Normal vs. COPD
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
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Natural History of COPD
FEV1 <70- dyspnea with
exercise
�
FEV1 <45-
Exacerbations/hospitalizatio
ns/dyspnea with ADLs
�
FEV1<30- Systemic
effects/dyspnea at
rest/respiratory failure
COPD and Co-morbids
Common co-morbids:
• Cardiovascular disease
• Lung cancer
• Osteoporosis
• Musculoskeletal
disorders
• Depression/anxiety
• Obesity/type II diabetes
Functional Impairments inPulmonary Disease
� Cough and abnormal
breath sounds
� Fatigue, weakness
� Loss of appetite
� Shortness of breath
following activity or lying
down
� Swollen feet and ankles
� Weight loss
� Shortness of breath,
dizziness or a choking
sensation, accompanying
chest pain
� Waking up from sleep
due to shortness of
breath when lying down
(Orthopnea)
21
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
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Systemic Effects of COPD
� Peptic ulceration
� Lung infections/lung cancer
� Weight loss/muscle wasting and weakness
� Hypoxemia and rising CO2 levels
� Pulmonary hypertension that may progress to
right ventricular hypertrophy and cor pulmonale
(right-sided heart failure)
� Osteoporosis
� Depression
Acute COPD Exacerbation
� Definition: Sustained worsening of symptoms from
patient’s usual condition; acute in onset
� Symptoms
� Increased shortness of breath
� Increased sputum production and/or increase in
purulence
� Increase cough
� Increased wheeze/chest tightness
� Decreased exercise tolerance
� Increased fatigue
� Altered mental statusNICE GUIDELINES 2004
IV: Very SevereIII: SevereII: ModerateI: Mild
Therapy at Each Stage of COPD
• FEV1/FVC < 70%
• FEV1 > 80% predicted
• FEV1/FVC < 70%
• 50% < FEV1 <
80%predicted
• FEV1/FVC < 70%
• 30% < FEV1 < 50% predicted
• FEV1/FVC < 70%
• FEV1 < 30%
predictedor FEV1 < 50% predicted plus
chronic respiratory failure
Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation
Add inhaled glucocorticosteroids if repeated exacerbations
Active reduction of risk factor(s); influenza vaccination
Add short-acting bronchodilator (when needed)
Add long term oxygenif chronic respiratory failure. Consider
surgical treatments
Adapted from GOLD Guidelines.
http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=
1&intId=989
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
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Management of Stage IV: Very
Severe COPD
Characteristics Recommended
Treatment• FEV1/FVC < 70%
• FEV1 < 30%
predicted or FEV1
< 50% predicted plus
chronic respiratory
failure
• Short-acting bronchodilator as needed
• Regular treatment with one or more LA bronchodilators
• Inhaled glucocorticosteroids if repeated exacerbations
• Treat complications
• Rehabilitation
• Long-term 02 therapy if respiratory failure
• Consider surgical options
Adapted from GOLD
Guidelines, 2007
Advanced COPD Management
� Long-acting and short-acting
bronchodilators (albuterol)
� Anticholinergics (ipatropium bromide or
tiotropium)
� Methylxanthines (theophylline)
� Combination inhaled therapies
(formoterol/budesonide)
� Inhaled corticosteroids- note: long term oral
steroids are not recommended however, 7-10
day course of prednisone may be helpful for
exacerbationsAdapted from GOLD Standards, 2007
Management of Advanced
COPD (cont’d)
�Antibiotics – reserved to treat infections; do not use prophylactically
�Opioids – oral and parenteral (not nebulized) to treat dyspnea
�Anxiolytics – helpful in managing anxiety associated with dyspnea
�Oxygen therapy – should be worn 15 hrs or > per day for greatest benefit
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
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End of Life Issues
�Prognosis difficult to predict
�Frequent exacerbations requiring trips
to the ED and/or hospitalizations
�Patients/family members frequently do
not comprehend the terminal nature of
the illness
�Lack of communication and
advanced care planning
� Isolation/depression/anxiety
Signs that Patient Requires
Palliative Care
� FEV1 < 30% predicted
� History of 2 or more exacerbations in past
year
� Frequent hospitalizations
� Progressive shortening of intervals
between admissions
� Limited improvement after hospitalization
Supporting
Indicators
• Declining functional
status/homebound
• Presence of co-
morbidities such as heart
failure or diabetes
• On maximum therapy and
dependence on oxygen
• Disabling dyspnea at rest.
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
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11
Establishing, Evaluating,
and Explaining
Eligibility Based upon Burden of Illness in COPD
Assessing and Documenting
Disease Burden in COPD
� Sustained tachypnea (RR>30
breaths/min)
� Sustained tachycardia (RR>100
beats/min)
� O2 saturation <88% on room air or
patient’s usual supplemental oxygen
� Hypotension <100mm Hg or 20% lower
than patient’s usual
� Severe impairment of ADLs
Assessing and Documenting
Disease Burden in COPD
� Inability to speak in full sentences
� Sustained use of accessory muscles of
respiration at rest
� Decreased ability to eat or sleep due to
respiratory distress
� Repeated lung infections/courses of
antibiotic therapy
� Hemoptysis/increased sputum
production/cough
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
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Assessing and Documenting
Disease Burden in COPD
� Sustained increase in
patient’s usual degree of
dyspnea
� Medication changes-
addition or titration of
opioids, anxiolytics, etc
� Altered mental status-
lethargy, confusion
� Increased caregiver
stress/burden
Activities and Participation
� Learning & applying knowledge
� General tasks and demands
� Communication
� Mobility
� Self-care
� Domestic life
� Interpersonal interactions and relationships
� Major life areas
� Community, social & civic life
35
ADL Documentation
Describe:
� How much caregiver support?
• None
• Minimal
• Moderate
• Total
� Time to completion of tasks
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
13
Environmental Factors
� Products and technology
� Natural environment and human-made
changes to environment
� Support and relationships
� Attitudes
� Services, systems and policies
37
Case Example:Pulmonary Disease
Referral #1: COPD
Mr. Smith
� Age: 76
� DX: COPD
� Residence: Home
� PCG: Wife
� PTA: 56 yr smoking
history; 5’9” 120 lbs,
BMI 17.7%
� Secondary
conditions: dyspnea,
cough, cachexia
� Co-morbid condition:
hypertension
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
14
Measurable Data Points
Pt: Mr. Smith DX: COPD SOC: 9/20/12
MEASURE PTA 9/20/12
Weight / BMI (5’9”) 140 120 / 17.7%
KPS/PPS - 50%
NYHA or FAST - -
ADL Dependency - Amb, transfer, dressing
and bathing
Skin - -
Infection Pneumonia -
Oxygen PRN 3L cont / 90%
Admission Note
� S – Pt reports, “I can’t do anything anymore
and I’m totally exhausted all of the time. I can’t
catch my breath, even when I’m sitting doing
nothing.”
� O – Using accessory muscles & purse-lipped
breathing; push of speech noted; dyspnea @
rest; amb X 50 feet w/o rest 2 months ago; now
rests 5-10 min after only 10 feet; uses W/C with
PCG assist to maneuver in house (too weak to
self-propel); O2 @ 3L via NC; sat = 88% RAR
Admission Note, Cont’d.
� Admitted with COPD
� Structural and functional limitations: � Impaired respiratory function: dyspnea at
rest, push of speech, purse-lipped breathing
� Oxygen dependent; O2 sat 88%� KPS 50 & 4/6 ADL dependency� Impaired mobility
� Weight loss
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
15
ICF Domains – COPDBody
Function
Body
Structure
Activity
Impairment
Participation
Impairment
Environmental
Factors
Dyspnea
with activity
Lungs Marked limitation
of physical
activity, unable to
propel
wheelchair
Essentially
homebound
Handicap
accessible
BR- Bedside
commode,
wc, O2
equipment
Fatigue/wea
kness
Dependent with
all ADLs
Loss of interest
in leisure
activities r/t
fatigue
Attentive
grandson
Favorite dog
Wheezing SOB inhibits
meaningful
interactions
Dyspnea with
conversations
24 hr PCG
Bipap
machine/
nebulizers
Admission Note, Cont’d.
� Secondary conditions:
� Pneumonia (onset, type & treatment)
� Extreme fatigue (AEBR)
� Productive cough (describe cough, treatment, response, etc.)
� Dyspnea with poor response to medication (describe)
� Oxygen-dependent (flow, pulse ox, etc.)
Admission Note, Cont’d.
� PMH:
� Increasing physician/ER visits and hospitalization for recurrent infections
�Pneumonia w/respiratory failure (6/28/12)
� Supporting documentation: unintentional >10% weight loss over past 6 mos.
� Fully meets Cardiopulmonary LCD guideline
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
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COPD Recertification
Documentation Example
“Patient is now completely bed-bound and
having new episodes of urinary incontinence.
Caregiver providing maximal assist with all
ADLs. Pt now severely dyspneic with minimal
activity, including trying to speak. Sleeping on
avg 18/24 hrs per day. PO intake reduced due
to coughing/choking episodes. Using MSO4 q 4
ATC with moderate relief”.
Conclusion� COPD is the 4th leading non-cancer
diagnosis in hospice
� Although irreversible and progressive,
COPD prognosis is difficult to predict
� Hospice eligibility and recertification is
based on the description of effects of
COPD on the structural, functional, activity,
participation and environmental domains,
plus documentation of secondary and co-
morbid conditions.
References
1. Global Initiative for Chronic Obstructive Lung
Disease (GOLD). Global Strategy for the
Diagnosis, Management, and Prevention of
Chronic Obstructive Pulmonary Disease (2007).
www.goldcopd.com
2. Poole, PJ, Veale, AG, Black, PN. Am J Respir Crit
Care Med 1998: 157: 1877-80.
3. International Classification of Functioning,
Disability and Health; World Health
Organization, 2001
4. NHPCO Facts and Figures, Nov. 2012
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
17
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, APRNVP, Strategic Initiatives
Weatherbee Resources Inc. & Hospice Education Network
tmaxwell@weatherbeeresources.com
Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease
Hospice Education Network (c) 2013
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