1. TTWP
Hunter Shomo

2. What does Hospice mean to you?

3. Hospice Administrative Spiritual Community Volunteers Medical RNs CNAs
Physicians

4. What is Hospice?
“We are a service dedicated to providing compassionate care and support for patient’s and their families during the final stages of life.”
“Comfort Care not Curative Care”

5. When does Hospice start?
Hospice care begins with certification of a physician
If the disease process follows its normal and projected course, death is expected in less than six months
Consult
Usually a SW and RN, can be any combination
Admission
SW and RN
Recertification
Occurs at regular intervals as regulated by Medicare
F2F visit with hospice Physician required

6. International program
Hospice programs are worldwide
Most of our patients are at home
Nursing facilities

7. How do we provide our service?
Primarily Medicare benefits
Donations
24/7

8. The Dying Experience “death comes in it’s own time, in it’s own way.”
“Death is as unique as the individual who is experiencing it.”

9. Stages of Death Withdrawal Food Water Disorientation Physical Changes
Approaching Death
Rally

10. Withdrawal Withdrawal from physical and outside sources is common
An inner processing and evaluation of life occurs
Increased sleep
Disinterest in previously interesting activity

11. Food Energy Fuel Socialization
All things dying patients don’t need or want

12. Water Same as food Body prefers to be dry
Organ shutdown makes digestion difficult
Increased negative side effects

13. Disorientation Apparent aimless activity Confusion Fidgeting
Talking to persons “not here”

14. Physical Changes
BP: typically lowers as compensatory mechanisms are ineffective
Pulse: tachycardia or bradycardia
Temperature: hot or cold
Skin: mottling, flushed, cool, pale, bluish
Breathing: bradypnea or tachypnea, congestion, cough
Hypoxia = Euphoria!!!
Waste: decreased urinary and bowel output

15. Approaching Death
Previously mentioned S/S may worsen, disappear, or begin
Typically S/S increase such as:
Mottling
Respiratory issues
Agitation
Rally
Saying goodbye
Giving permission

16. Rally Sudden surge of energy May speak clearly
May want family presence
Can be confusing to family and caregivers
False hope

17. Saying Good-Bye Speak openly and often Say “ I love you”
reconciliation
No regrets!

18. Giving Permission Offer permission to die Don’t make them feel guilty
Their needs above yours

19. Death Restless or Peaceful
Cheyne-stokes respirations progress to apnea
Increased irregularity leading to apnea
Apnea x 3 minutes
Pulseless
Apical and peripheral

20. How does the Hospice Team help?
Education
Pharmacologic measures
Support
Advocate

21. Pharmacologic Interventions
Comfort Kit
Stopping prescribed medications
Tailoring pharmacological regimen to patient specific needs

22. Comfort Kit Acetaminophen Dulcolax Morphine Ativan Hyoscyamine
Haloperidol

23. Acetaminophen For: fever or pain Supply: 650mg Suppository
Action: analgesia by inhibiting prostaglandin and antipyretic through central action in the hypothalamic regulating center
When to administer: Fever or mild pain, when unable to swallow

24. Dulcolax For: constipation Supply: 10mg Suppository
Action: Stimulant laxative that increases peristalsis via direct effect on the smooth muscle in the intestine and stimulating the colonic intramural plexus. Also fluid accumulation in the colon and small intestine.
When to administer: Constipation x 3 days and as part of bowel regimen related to narcotic induced constipation

25. Morphine For: Pain and Dyspnea
Supply: 30mL per bottle 20mg/1mL, 100mg/5mL
Action: Alters perception and emotional response to pain by activation of receptors in the central nervous system and bowel.
When to administer: severe pain or dyspnea.
Mainly used for breakthrough pain, if needed long term, should consider adjunctive therapy or long acting medication such as MC Contin.

26. Ativan For: Agitation or anxiety Supply: 1mg tablets
Action: Benzodiazepine that acts on GABA receptors to depress CNS activity,
When to administer: terminal restlessness, anxiety and agitation

27. Hyoscyamine For: terminal secretions
Supply: mg sublingual tablets
Action: reduces gastric acids and salivation by it anticholinergic effects
When to administer: terminal secretions, “death rattle”

28. Haloperidol For: nausea or agitation Supply: 30mL 2mg/mL
Action: antipsychotic effects by blocking postsynaptic dopamine receptors
When to administer: nausea, as an adjunct to other antiemetics or stand alone, terminal restlessness

29. Medication Reduction
Patients and families are often reluctant to stop long standing medications previously seen as useful.
Often these medications have undesirable side effects and are no longer needed.

30. Adding medications
Comfort kit is mainly used for the terminal phase of end of life care Hospice staff works to add medications such as antiemetics and other symptom specific medications to produce comfort

31. Why Hospice in facilities?
“We can provide the same care you can”
“We know our patient’s better than you.”
“We have our own system”

32. Questions?