Hospice Basics and Benefits

Goal

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

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

All of Us Will Die

<10% suddenly, unexpected event, heart attach (MI), accident, etc…

>90% protracted life-threatening illness• Predictable steady decline with a relatively short

“terminal” phase (cancer). • Slow decline punctuated by periodic crises (CHF,

emphysema, Alzheimer’s)

Dying in the 19th Century

3% of America’s population was >65

Life expectancy was 45-50 years

Most people died at home

Dying in the United States Today

13% of the population is > 65 years Approximately 75% of Americans die in

health care facilities • 57% die in hospitals• 17% die in long

term care facilities

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.

History of Hospice Linguistic root words

•Hospital•Hospitality•Shelter•Respite•Caring

A place of refuge and solace

Hospice History: U.K.

1905 St. Joseph’s Sisters of Charity in London 1967 St. Christopher’s 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

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

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

Oxford’s Textbook of Palliative Medicine

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.”

World Health Organization

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

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

Patient Appropriateness

Life-limiting illness Medicare regulations

•Six months or less prognosis•Two physicians

Patient and/or family request

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

Non-Oncology Diagnoses End Stage

• Cardiac• Pulmonary• Alzheimer’s Disease• Renal Disease• Liver• Stroke (Acute & Chronic)• ALS (Lou Gerhig’s disease)

Debility Unspecified AIDS

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

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!

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

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

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

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

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!

Four Levels of Hospice Care1. Routine Home Care

2. Continuous Care

3. Inpatient Care

4. Respite Care

Ethical Issues Ethics Committees Advance Directives Do Not Resuscitate Order (DNR)

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

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!

Do Not Resuscitate Orders (DNR)

DNRs communicate a patient’s wishes regarding the use of cardio-pulmonary resuscitation

Patients are not required to sign a DNR in order to elect or receive hospice care

Partner with Hospice Benefit from hospice’s rich history Know criteria used to identify the hospice

appropriate patient Ask: could the patient’s 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

“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. Christopher’s Hospice,

London, England

ReferencesFerrell, 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?pageID=3254

Puchalski, C., & Ferrell, B. (2010). Making Health Care Whole Integrating Spirituality into Patient Care. West Conshohocken, PA: Templeton Press.

Hospice Basics and Benefits