hospice

Introduction

• 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

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 expressed goals of care should direct care
• pain management
  • see pain management in palliative 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, Medicaid, VA & most common commercial insurance carriers pay for hospice services
  • 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
    • reistered 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
      • palliative radiation therapy for painful bone metastases are a covered & effective benefit
    • 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

• 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