1. Introduction to Hospice and Palliative Medicine
Bansari Patel, APN, ANP
Joan Bigane, APN, FNP
University of Chicago Medical Center

2. Case Study
Mr. H is a 77 y/o AAM with history of Stage 4 Non-small cell lung cancer. He was initially diagnosed August 2010, after he presented with a persistent cough for 2 months. He has been treated with chemotherapy and radiation. He presents to clinic with worsening SOB and fatigue. The imaging you ordered shows that he has progression of his disease in lung and liver. After reviewing this with him, you ask if he would like to pursue additional chemotherapy.
He responds: “I don’t want any more chemo, can’t you do anything else to make me feel better ?”
How would you respond to Mr. H?

3. Case Study
As Mr. H’s health provider, you have seen the progression of his symptoms/disease and feel that he is appropriate for hospice level care and discuss that with Mr. H.
Mr. H asks “What exactly does hospice care mean?”
Can anyone answer Mr.H? The definition of hospice according to the CAPC is a program of care for pts. And their families with a terminal illness that addresses physical,emotional,and spiritual needs.It is provided by an interdisciplinary team of professionals and volunteers guided by an individual plan of care.

4. Hospice Experience Model
Physical Dimension (perceived distress/discomfort)
Functional Dimension (perceived ability to perform ADLs and IADLs)
Interpersonal Dimension (perceived quality of relationships)
Well-being Dimension (perceived sense of “dis-ease”)
Transcendent Dimension (perceived spiritual connection)
Labyak M, Egan K, Brandt K. The experience model: Transforming the end-of-life experience. Hospice and Palliative Care insights 2002;2:9-14
Physical dimension ( pain/symptom needs controlled per MD, APN's, nurses, pharmacist)
Functional dimension (bathing, dressing, grooming per nurse assistant, nurse or PT for strengthening)
Interpersonal dimension ( counselors, SW, psychologist, chaplain & volunteers)
Well-being dimension ( counselors, SW, chaplains, psychologist) ( contentment or lack of contentment)
Transcendent dimension (chaplains, counselors, SW, psychologists) ( how one perceives the meaning of life)

5. General Principles of Hospice
Philosophy of care, not a place
Focus on compassionate, holistic end-of-life care
Patient still has autonomy and decision making
Care is directed by the patient and family
Dignity/Respect for patient and family
Can anyone tell me where hospice can take place? Home, NH, assisted living centers, jails, hospitals

6. Hospice Q&A
Mr. H asks you “What services will hospice provide me home?”
Nursing PT/OT/ST
Physician Trained volunteers
Social Worker Respite
Spiritual Support Bereavement Support
Homemaker CAM

7. Hospice Q & A Mr. H asks : “How long has hospice care been around?”
“Will I still be able to see my doctor?”
“Who pays for it?”
“Am I eligible under medicare?”

8. History of the Hospice Movement
Evolving since the 11th century
The hospice movement in the United States has its roots in the work of British physician Dame Cicely Saunders and Dr. Elisabeth Kubler-Ross.
In 1967:,Dr. Saunders founded the first modern hospice -- St. Christopher's Hospice in London, England.
The first hospice in America, the Connecticut Hospice, opened in 1974, followed shortly by an in-patient hospice at Yale Medical Center and a hospice program in Marin County, California
Four years later, the U.S. Department of Health, Education and Welfare published a report citing hospice as a viable concept of care for terminally ill people and their families that provides humane care at a reduced cost.
Hospice an old European term for a house of comfort for tired or sick travelers. It started as a grass root effort to bring back dignity to the dying and comfort them. Seen as an alternative to overuse of technology and lack of symptom control for dying pts.

9. History of the Hospice Movement
Early 1980s, Congress created legislation establishing Medicare coverage for hospice care. The Medicare Hospice Benefit was made permanent in Today most states also provide hospice Medicaid coverage.
Today there are more than 3,200 hospices across the country - some are part of hospitals or health systems, others are independent; some are nonprofit agencies, others are for-profit companies
According to the National Hospice and Palliative Care Organization, in 2000 about 1 in 4 Americans who died received hospice care at the end of life - roughly 600,000 people.

10. How are hospice services covered?
Private Pay
Some insurances: BlueCross; Aetna; UCHP
Medicaid
Medicare Hospice Benefit
If 2 physicians agree that pt has less than 6 months to leave, then they are eligible for medicare hospice benefit.pt signs off medicare Part A (hospital payment) for his dx of cancer and he would enroll in medicare hospice benefit with direct care provided by the hospice.The hospice is [aid a per-diem rate of 140..dollars/day for nursing,sw, meds,dme.It does NOT include custodial care.(medicaid,private pay, LTC insurance policies)pts can sign off at anytime.4/5 hospice pts are 65 yrs older
1/3 of pts enrolled in hospice die in 7 days or less..In 200 the average length of stay was 24 days.. Hospice care accounts for about 1% of medicare spending..medical care at the end of life consumes 12% of the total healthcare budget and 28% of medicare budget.comparing the costs of hospice with conventional care medicare saves $1.52 for every $1 spent on hospice care.

11. Case Study
Mrs. G is a 46 y/o woman w/ metastatic breast cancer to her spine. She is currently receiving chemotherapy and has completed radiation to her spine. She presents today with pain to her low back and anxiety. She currently is on long acting opioids and breakthrough opioids. She tells you that it’s not helping. You order imaging of her spine and increase her pain medications.

12. Case Study The imaging shows stable metastatic disease.
You increase her opioids and bring up the idea of having a palliative medicine team consult.

13. Palliative Care Q & A Mrs. G asks you:
“What is Palliative Medicine? Is this something new?”
“What services are provided?”
“How much does it cost?”
“How often will I get a visit”
“Will I still be able to get my chemotherapy?”
“Does this mean I’m dying?”

14. Palliative Care Services
Treatment to relieve pain and other symptoms
Individual and Family counseling
Emotional and spiritual support, including attention to end-of-life concerns
Help in advance care planning
Assistance with treatment choices and decisions
Home visits (provided by outpatient-based Palliative Care teams)
Help in transitioning to hospice care

15. History of Palliative Care
First US hospital-based palliative care programs began in the late 1980’s
Cleveland Clinic & Medical College of WI.
Dramatic increase in hospital-based palliative care
Board certified specialty
More than 50 fellowship programs

16. Reimbursement Medicaid Private Insurance Out of pocket Grants
Not Medicare, per se

17. Benefits of Hospice/Palliative Care
Relieves pain and suffering
Helps with difficult decision making
Palliative care helps patients complete prescribed therapies
Boosts patient and family satisfaction
Continuity of care
Cost saving
Various studies on the cost effectiveness of hospice/palliative care have provided strong evidence that this a less costly approach to care for the terminally ill. In 2005 Avg daily hospital inpatient charges were $4,787, whereas hospice charges per day of care were approximately $131.

18. Thought for the day:
When I was 5 years old, my mom always told me that happiness was the key to life.
When I went to school, they asked me what I wanted to be when I grew up.
I wrote down “happy.”
They told me I didn’t understand the assignment
And I told them they didn’t understand life.
-Anonymous