hospice

Indications

• see hospice guidelines for determining prognosis for eligibility

Complications

• hypoglycemia among hospice patients with type 2 diabetes receiving insulin is common
  • 38% in diabetics receiving insulin
  • 12% in diabetics not receiving insulin

Management

• consistency with patient's exoressed goals of care should direct care
• alleviation of pain (if patient's stated primary value) takes precedent over concerns of sedation or family's concerns
  • confirm with patient until decision making capacity is lost

Notes

Developed as a nursing-led response to perception of uncaring, technologically-driven care for dying patients.

caregivers of hospice patients report better experiences with not-profit hospices than with for-profit hospices

29% of deaths in the year 2000 were in hospice.

Eligibility:

General guidelines for hospice:

• prognosis of 6 months or less as determined by 2 physicians
  • specific diagnosis
  • combination of factors
  • no specific diagnosis necessary
• patient & or family must have elected treatment goals directed relief of symptoms, rather than cure of underlying disease
  • a "do not resuscitate" status is not required
• functional assessment tool (FAST) score of 7c or worse

* Medicare Part A finances hospice services in the elderly. (see medicare hospice benefits)

* Patients are disenrolled in Medicare Part A upon enrollment in hospice

Hospice settings:

• hospice is most commonly delivered in the home setting
  • requires a caregiver who is able to provide full-time care
• inpatient hospice units are increasing in prevalence
  • all hospice programs are required to have inpatient care available
  • reimbursement schedules do not provide adequate financial incentives for inpatient care other than management of acute palliative crises
  • transition of intensive care unit patients to inpatient hospice is feasible

Hospice services:

• care provided by an interdisciplinary team
  • physician supervision & services
  • nurse/care manager
  • social worker
  • chaplain
  • physical therapist
  • occupational therapist
  • speech therapist
  • dietician
  • aids, volunteers
• care management by a hospice nurse
• access to a hospice physician
• medications, tests & other treatments at no cost
  • provided they are related to the terminal diagnosis & are palliative
  • medications not covered by hospice are not covered by Medicare part D
• durable medical equipment
• bereavement services for 13 months after a death
• not provided by hospice
  • subacute nursing home care
  • private duty caregiver
  • room & board
  • skilled-nursing care

Initiating a discussion about hospice

• assess patient's perception of medical condition & goals of care
• there is no way to know how much a patient wants to know or to be involved in decision-making processes without asking
• if appropriate, explain hospice services
• empathize with patient
• summarize & strategize

Barriers to increasing use of hospice services:

• restrictive medicare eligibility requirements & low reimbursement rates
• reluctance of providers to refer until the final days/weeks of life
• hospice philosophy
  • many hospices do not accept patients who would like readily treatable, reversible intercurrent illnesses treated if possible
• mistrust of the healthcare system is a barrier
• educational status is not associated with hospice refusal among black Americians

Cost effectiveness

• patients who have cancer with poor prognosis who enter hospice use less intensive medical care & cost less to care for (median hospice duration 11 days)
  • utilization less, but still high
    • hospital admissions (42% vs 65%)
    • admissions to intensive care (15% vs 36%)
    • invasive procedures (27% vs 51%)
  • hospice patients less likely to die in the hospital (3% vs 50%)

Reasons for discharge from hospice alive

• hospice revoked because patient dialed 911 & was admitted to an acute-care hospital (42%)
  • black, hispanic, & Asian patients more likely to have hospice revoked due to acute-care hospital admission than non-hispanic whites
• patient revoked hospice to resume disease-directed treatments without acute hospitalization (18%)
• patient no longer certified as terminally ill (14%)
  • patients with non-cancer diagnosis more likely to become no longer certified as terminally ill
• patient moved out of service area or transferred to another hospice (26%)

Additional terms

• basic activities of daily living (bADL, Katz)
• functional assessment staging (FAST)
• hospice guidelines for determining prognosis
• impending death
• Karnofsky performance index (palliative performance scale)
• Medicare hospice benefits
• palliative care
• palliative prognostic measure

Patient information

hospice patient information