Hospice Care vs - MemberClicks · discharge to LTC/SAR •Symptoms include dyspnea and debility...

2018 MICNP Conference 3/17/2018

1

SM

Hospice Care vs Palliative Care

Easing the burden of illness,Improving quality of life

Seasons Hospice and Palliative CareCheryl Ledesma, FNP-BCJacklyn Griffin, ACNP-BC

SM

Objectives

After completing this course the learner will be able to:

• Define Palliative Care• Explain how Palliative Care differs

from Hospice• List common conditions and symptoms

treated by Palliative Care


2

SM

Palliative Care Defined

• Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

SM

• Palliative care, and the medical sub-specialty of palliative medicine, is specialized medical care for people living with serious illness. It focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve quality of life for both the patient and the family.



3

SM

• Palliative care is provided by a team of palliative care doctors, nurses, social workers and others who work together with a patient’s other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.


SM

Palliative care:

• Provides relief from pain and other distressing symptoms;

• Affirms life and regards dying as a normal process;

• Intends neither to hasten or postpone death;

• Integrates the psychological and spiritual aspects of patient care;


4

SM

• Offers a support system to help patients live as actively as possible until death;

• Offers a support system to help the family cope during the patients illness and in their own bereavement;

• Uses a team approach to address the needs of patients and their families, including bereavement counseling, if indicated;

SM

• Will enhance quality of life, and may also positively influence the course of illness;

• Is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing clinical complications.


5

SM

SM

Palliative Care and Hospice Differences

Continued next slide

Palliative Care Hospice

Comparable to a house call practice or a subspecialist (such as cardiology or pulmonology)

Medicare benefit program

Consults / visits provided by MD or NP for symptom management related to an advanced illness

Services provided by interdisciplinary team including physicians, nurses, social workers, chaplains, music therapists, home health aides, volunteers, etc.

Visits occur anywhere from every day to once per month based on clinical needs.

Visits occur usually twice per week by nurse, and twice per week by home health aide. Physicians visit PRN.


6

SM


Continued next slide


No requirement for prognosis of lessthan 6 months

Required to have a prognosis of 6 months or less

Services are consultation based. Curative measures can be maintained (chemo, radiation, surgeries, dialysis, etc.)

Services are comprehensive and include DME, medications related to terminal diagnosis, 24 hour support

Patient can be accessing home health or skilled nursing days

Patients forego skilled rehab, home health and curative treatments

SM



Billed through Medicare Part B Billed through Medicare Part A

Palliative specialist receives Medicare, Medicaid and private insurance reimbursement depending on billing code (CPT and ICD-10)

Hospice receives a per diem rate from Medicare depending on the level of care (4 levels)

Patient is responsible for copay based on consultation rate

Insurance reimburses case-by-case, carve out for certain treatments, such as TPN


7

SM

Palliative Care

• Can be provided along with other therapies intended to prolong life, such as chemotherapy or radiation therapy

• Includes those tests or investigations needed to better understand and manage distressing clinical complications

• Important to note: patient can have a life expectancy of more than 6 months but still have a chronic and ultimately terminal illness

SM

Chronic Illnesses Addressed by Palliative Care include:

• Cancer• Congestive heart failure• Chronic kidney disease• Chronic pulmonary disease• Dementia (unspecified and

Alzheimer-type)• Liver disease• Cerebrovascular disease/CVA• Parkinson’s disease• HIV/AIDS


8

SM

What is Our Goal at the End of Life?

https://youtu.be/JD_Wrl7PlBE

SM

• Elderly female with past medical history of end stage COPD status post multiple hospitalizations

• Goals of care included maximal independence, peaceful end of life, refer to hospice once skilled days have been exhausted

• Symptoms included debility and dyspnea• Advanced directives needed to be addressed

and updated

Palliative Care vs Hospice

Would this patient be more appropriate for palliative care or hospice care?


9

SM• 65 year old female with past medical history of newly

diagnosed small cell lung cancer, presented to ED with complaints of SOB

• Chest x-ray shows right lung completed whited out, EGD shows advancing mass compressing right bronchus with right lung completed obstructed

• Complete opacification of right lung• Elective intubation next day due to worsening

respiratory status• Goals of care included palliative radiation to right lung

and chemotherapy with end goal of extubation and discharge to LTC/SAR

• Symptoms include dyspnea and debility• Advanced directives needed to be addressed and

updated


SM

• 63 year old women who was diagnosed with lung cancer

• Not aware that she was “stage 4” until a new oncologist took on her case

• Wanted to continue radiation therapy even though she was very weak and in a lot of pain

• She had goals to get “affairs in order”• Difficulty eating due to dyspneaWould this patient be more appropriate for palliative care or hospice care?



10

SM

Palliative Care vs Hospice• 101 year old female with dementia and

Grade I congestive heart failure on palliative care service for over one year

• Stable until September 2016 when she sustained a couple of falls and began intermittent wandering at night

• November 2016 suffered a right femur fracture and underwent an ORIF

• Post- operatively suffered from increased lethargy, albumin dropped below 2

• Decrease in functionality

Would this patient be more appropriate for palliative care or hospice care?

SM

• “The Usual Suspects” – progressive life-limiting illness ▫ Incurable cancer▫ Progressive, advanced organ failure (heart, lung,

kidney, liver)▫ Advanced neurodegenerative illness (ALS,

Alzheimer’s Disease)• Sudden fatal medical condition

▫ Acute stroke▫ Withholding or withdrawing life-sustaining

interventions (ventilation, dialysis, pressors, food/fluids…)

▫ Trauma – eg. head injury▫ Ischemic limbs, gut▫ Post-cardiac arrest ischemic encephalopathy▫ etc

Potential Palliative Conditions


11

SM

Symptoms often managed by Palliative Care:

• Pain• Dyspnea• Nausea and Vomiting• Cachexia and Anorexia • Pruritus• Anxiety/Depression• Delirium• Constipation• Restlessness and agitation• Sleep disorders• Fatigue

SM

• 91 year old female diagnosed with CHF, renal failure and COPD

• 20-25 % ejection fraction• Oxygen dependent 4L NC, desat without

NC O2• Hospitalized for edema of lower extremities• Returned to facility with a LifeVest• Family/resident were told that LifeVest

would improve heart function

Positive Impact of Palliative Care Involvement


12

SM

• 89 year old women diagnosed with dementia• Having syncopal episodes at Memory Care

Unit• Palliative Care NP found out that episodes

were occurring primarily in the morning• Palliative Care NP collaborated with

attending MD to change long acting beta blocker from being given in the evening to being given in the morning (with parameters)

• No further syncopal episodes• Avoided injury, hospitalization, workup and

overall improved quality of life.


SM


• 55 year old female with early onset of Alzheimers with behavioral issues. Past medical history of bipolar disorder, post traumatic stress disorder and obsessive compulsive disorder

• Goals of care are psychological comfort (improved behaviors and compliance)

• Symptom of increased agitation• Weight loss• Full code


13

SM

Potential Palliative Care Interventions

Control of• Pain• Dyspnea• Nausea• Vomiting

Support• Emotional• Spiritual• Psychosocial

CPR

Ventilation

Highly burdensomeInterventions

Infections

Transfusions

Hypercalcemia

DialysisTube Feeding

Palliative Generally Not Palliative

Variable

SM

Advanced Care Planning/Goals of Care•Health care proxy/surrogate decision maker

•Establishing wishes in the event of serious illness or acute event

•Clarifying code status

•Family meetings

•Communication/Documentation of patient wishes to the rest of the health care team.


14

SM

SM

Palliative Care Triggers

• You would not be surprised if the resident/patient died within 12-18 months

• You’re aware the resident/patient has 3 or more chronic illnesses and is on multiple medications

• You’ve noticed the residents/patients goals of care re inconsistent, he/she lacks an advanced directive, or there’s disagreement among family members about the plan of care


15

SM

• You’ve had to send the resident/patient to the hospital at least twice in the last 6 months

• You’ve had trouble controlling the resident’s/patient’s physical or psychological symptoms

• You’ve noticed the resident/patient is becoming more difficult to feed, is losing weight, or has a declining functional status

Palliative Care Triggers

SM

Overall Benefit of Palliative Care Consultations• Reduced symptom burden of

chronic/terminal illness• Early integration of palliative care may

prevent the use of aggressive care in outpatient settings

• Identifies goals of care and advocates for patient wishes

• Cost avoidance• Increase in quality of life


16

SM

References• Alexander, K., Goldberg, J., & Korc-Grodzicki, B. (2016).

Palliative care and symptom management in older patients with cancer. Clinics in Geriatric Medicine, 32, 45-62.

• Bushor, L., & Rowser, M. (2015, August). Symptom management of adult chronic illness in the outpatient setting. Journal of Hospice & Palliative Medicine, 17, 285-290.

• Buss, M. K., Rock, L. K., & McCarthy, E. P. (2017, February). Understanding hospice and palliative care: A guide for primary care providers. Mayo Clinic Proceedings, 92, 280-286.

• Center to Advance Palliative Care. Palliative Care definition https://www.capc.org/about/palliative-care/

SM

References• Dahlin, C., Coyne, P. J., & Ferrell, B. R. (Eds.). (2016).

Advanced practice palliative nursing. New York, NY: Oxford University Press. 6. Miller, S. C., Lima, J. C., Intrator, O., Martin, E., Bull, J., & Hanson, L. C. (2016, September 19). Palliative Care Consultations in Nursing Homes and Reductions in acute care use and potentially burdensome end-of-life transitions. Journal of the American Geriatrics Society, 64, 2280-2287.

• World Health Organization (WHO) Definition of Palliative Care. (2017). Retrieved from http://www.who.int/cancer/palliative/definition/en/


17

SM

Contact Information

• Jacklyn Griffin- [email protected]

• Cheryl Ledesma- [email protected]

Hospice Care vs - MemberClicks · discharge to LTC/SAR •Symptoms include dyspnea and debility...

Documents

Transcript of Hospice Care vs - MemberClicks · discharge to LTC/SAR •Symptoms include dyspnea and debility...