Hospice Basics and Benefits | VITAS Healthcare
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This document outlines the basics and benefits of hospice care, emphasizing its importance for patients and families dealing with advanced illness. It details the eligibility criteria for hospice services, the difference between curative and palliative care, and the comfort and support provided by hospice professionals. Additionally, it discusses the role of advance directives, the financial aspects of hospice care, and common myths surrounding hospice services.
Hospice Basics and Benefits | VITAS Healthcare
- 1. Hospice Basics and Benefits
- 2. CE Provider Information VITAS® Healthcare programs in California/Connecticut/Delaware/ Illinois/ Northern/Virginia/Ohio/Pennsylvania/Washington DC/ Wisconsin are provided CE credit for their Social Workers through VITAS Healthcare Corporation, provider #1222, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org, through the Approved Continuing Education (ACE) program. VITAS Healthcare maintains responsibility for the program. ASWB Approval Period: (06/06/2021-06/06/2024). Social Workers participating in these courses will receive 1 clinical continuing education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}. VITAS® Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS® Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021-06/06/2024. Social workers completing this course receive 1.0 continuing education credits. VITAS® Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2023. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.
- 3. Goal The goal of this presentation is to educate nurses and other healthcare professionals about hospice basics and hospice care’s benefits for the patient and family.
- 4. Objectives • Describe the history, philosophy, and benefits of hospice • List 2 or more criteria used to identify the hospice-eligible patient and some diseases commonly seen in end-of-life care • Identify the difference between curative and palliative care • Explain Medicare reimbursement for hospice • Discuss the relevance of advance directives and do-not-resuscitate (DNR) orders when discussing hospice services
- 5. 1Werner, C. (2011). The Older Population: 2010 US Census Bureau. Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf 2 Arias, E. (2003). United States Life Tables, 2003. US Centers for Disease Control and Prevention, National VITAL Statistics Reports, 54:14. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf 3United States Census Bureau (2017). Facts for Features: Older Americans Month, May 2017. Retrieved from: https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html 4Xu, J., et al. (2020). Mortality in the United States, 2018. NCHS Data Brief, January 2020. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db355.htm 5 Xu, J. (2016). Percentage Distribution of Deaths, by Place of Death-United States, 2000-2014. US Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a6.htm Dying Then and Now 19th Century: • In 1900, 4% of America’s population was > 651 • In 1900, life expectancy was 49 years2 • Most people died at home Today: • Nearly 15% of the U.S. population is > 65 years3 • 2017 life expectancy in the U.S. was 78.7 years4 • Approximately 37% of Americans die in acute- care hospitals and 19% die in nursing homes5
- 6. How People Die • < 10% die suddenly of an unexpected event, heart attack (MI), accident, etc. • > 90% die of a protracted, life-threatening illness – Predictable steady decline with a relatively short “terminal” phase (cancer) – Slow decline punctuated by periodic crises (advanced cardiac disease, advanced lung disease, Alzheimer’s/dementia) Emanuel, L., et al. (2003). The Education in Palliative and End-of-Life Care Curriculum (EPEC Project). Northwestern University Feinberg School of Medicine.
- 7. Theoretical Trajectories of Dying 0% 20% 40% 60% 80% 100% Frailty Organ Terminal Sudden Percent of Each Clinical Group Belonging to Each Latent Trajectory Group Late Progressive Moderate Early Persistent Lunney, J., et al. (2018). Mobile trajectories at the end of life: Comparing clinical condition and latent class approaches. Journal of the American Geriatrics Society, 66(3): 503-508. doi: 10.1111/jgs.15224. A study of patients who self-reported mobility at 6-month intervals during the last 3 years of life provides insights into theoretical trajectories of dying. Whether death was sudden or the result of organ failure, a terminal disease, or frailty, the research identified trajectories along a scale from persistent disability to late decline.
- 8. Hospice History • Linguistic root words – Hospital – Hospitality – Shelter – Respite – Caring • A place of refuge and solace
- 9. Hospice History (cont.) • 1967 Dame Cicely Saunders opened St. Christopher’s in London • 1969 book “On Death and Dying” by Elisabeth Kübler-Ross brought the topic into the mainstream • 1974 New Haven Hospice of Connecticut is established • 1976 Hospice Care, Inc. (now VITAS) is established • 1978 National Hospice and Palliative Care Organization (NHPCO) forms for those providing care for advanced illness patients – Mission: “To lead and mobilize social change for improved care at the end of life”
- 10. Reinforcing Hospice Facts Hospice is a place. False. This is one of the commonly held myths about hospice. Hospice care generally takes place in the person’s home, whether a private residence, nursing home, or assisted living community. Some hospitals have dedicated hospice beds, and some communities have freestanding hospice care centers or inpatient units. However, the majority of people prefer to spend their final days wherever they call home.
- 11. 28% 13% 13% 13% 8% 11% 14% Days of Hospice Care Per Patient 2018 1-7 days 8-14 days 15-30 days 31-60 days 61-90 days 91-180 days >180 days Proportion of Patients by Days of Hospice Care National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures
- 12. Hospice Eligibility • Advanced illness • Medicare regulations – Prognosis of 6 months or less – Two physicians certify the patient as being terminally ill with a life expectancy of 6 months or less if the terminal illness runs its normal course • Patient and family have agreed to a care plan with goals that are palliative in nature, primarily focused on management of physical, psychosocial, emotional, and spiritual symptoms
- 13. Reinforcing Hospice Facts You don’t need hospice until a few days before you die. False. Ideally, patients and families choose hospice upon receiving a prognosis of 6 months or less if the illness runs its normal course. This affords the patient and family the ability to receive optimal medical management and symptom relief in the comfort of their own home. Patients do not need to be homebound to be eligible for hospice services. NHPCO experts say the ideal time for hospice care is 6 months.
- 14. 29.6 17.4 15.6 14.7 11 9.5 2.2 Cancer Heart Disease Dementia Other Respiratory Stroke Kidney 0 5 10 15 20 25 30 35 2018 Percentage of Hospice Patients by Diagnosis National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures
- 15. Reinforcing Hospice Facts Hospice helps people with advanced illness die more quickly. False. In reality, just the opposite occurs. Research published in the Journal of Pain and Symptom Management found that Medicare beneficiaries who opted for hospice care lived an average of 29 days longer than similar patients who did not take advantage of hospice. Hospice improves quality of life for patients with advanced disease. Connor, S., et al. (2007). Comparing hospice and nonhospice patient survival among patients who die within a three-year window. Journal of Pain and Symptom Management, 33(3), 238-246.
- 16. Curative Palliative Disease-driven Symptom-driven Doctor is in charge Patient is in charge Disease process is primary Disease process is secondary to person Few choices Many choices Evidence-based treatments Comfort and quality of life Curative Care vs. Palliative Care
- 17. 14% 3% 5% 8% 70% How knowledgeable are you about palliative care? Somewhat knowledgeable Knowledgeable Very knowledgeable Don't know Not at all knowledgeable Consumer Awareness About Palliative Care Fulmer, T., et al. (2018). Physicians’ views on advance care planning and end-of-life care conversations. Journal of the American Geriatrics Society, 66(6), 1201-1205.
- 18. What Is Palliative Care? Cherny, N., et al. (2015). Oxford Textbook of Palliative Medicine (5th ed.). Oxford University Press. The study and management of patients with active, progressive, far-advanced disease for whom the prognosis is limited and the focus of care is quality of life. —Oxford Textbook of Palliative Medicine
- 19. Palliative Care • Manages pain and symptoms • Regards dying as a normal process • Neither hastens nor postpones death • Integrates psychological and spiritual care • Supports patient and family • Incorporates a team approach • Enhances quality of life • Applicable early in the course of illness
- 21. Non- Oncology Diagnoses – Cardiac disease (heart failure) – Lung disease (COPD, emphysema) – Alzheimer’s/ dementia and other neurological disease (chronic and acute stroke) – Sepsis – Renal disease – Liver disease (end-stage cirrhosis) – ALS (Lou Gehrig’s disease) – AIDS Medicare regulations • End-stage and/or advanced:
- 22. Oncology (Cancer) Diagnoses • Breast • Bone • Renal cell • Pancreatic • Bladder • Glioblastomas • Lung • Colon • Advanced prostate with metastasis • Head and neck • Hematologic malignancies
- 23. Disease Progression Decline in functional status: – PPS ratings of < 50-60% – Dependence in 3 of 6 activities of daily living (ADLs) Deterioration in clinical condition in the past 4-6 months: – Multiple hospitalizations or ED visits – Decrease in tolerance to physical activity – Decrease in cognitive ability • Other comorbid conditions • Pain and difficulty breathing
- 24. Reinforcing Hospice Facts Hospice is a last resort when nothing else can be done. It is giving up! False. When optimized medical treatments can no longer cure a person who has an advanced illness, hospice professionals can do many things to: • Control symptoms and pain • Reduce anxiety • Offer spiritual and emotional support • Improve quality of life for patients with advanced illness and their families
- 25. End-of-Life Symptoms Unrelieved pain • Dyspnea • Congestion • Dysphagia • Anorexia/cachexia • Agitation/restlessness • Confusion/delirium • Disrupted sleep • Nausea/vomiting • Bowel obstruction
- 26. Reinforcing Hospice Facts Hospice discontinues all medications and treatments. False. Patients can continue treatments that provide symptom relief and improve quality of life. • For example, a patient with advanced lung disease who is currently on inhaler therapy that allows them to breathe better can continue this therapy while receiving hospice care.
- 27. Reinforcing Hospice Facts: True/False Hospice administers morphine to hasten death. False. When a patient is on hospice, a plan of care is established together with the patient and family. • This plan of care is individualized and based on the patient’s specific physical and psychosocial needs. • Only if needed to relieve shortness of breath, pain, or the active phase of dying, a hospice physician can prescribe the lowest effective dose of morphine to provide comfort. • Not every patient on hospice requires or receives morphine. Many other pharmacological and non- pharmacological approaches are available.
- 28. End-of-Life Symptoms • Psychosocial – Depression – Anxiety – Ineffective coping and communication – Life-role transition – Caregiver distress • Spiritual – Despair/hopelessness/isolation – Powerlessness – Lack of meaning – Loneliness – Need for reconciliation
- 29. $15.1 B $15.9 B $16.8 B $17.9 B $19.2 B 2014 2015 2016 2017 2018 Medicare Spending Medicare Spending and Hospice National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures
- 30. 0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 In-hospital Deaths ICU Admissions 30-Day Hospital Readmissions Incremental Reduction in Various Outcomes (Proportional) 53-105 days 15-30 days 8-14 days 1-7 days Hospice Impact Kelley, A., et al. (2013). Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Affairs, 32(3), 552-561.
- 31. Medicare Hospice Benefit These services are mandated by the Medicare hospice benefit. Interdisciplinary Team of Hospice Professionals Home Medical Equipment Medication Bereavement Support Continuous Care Respite Care Routine Home Care Inpatient Care
- 32. 85% 7% 5% 1% 1% 1% Medicare Hospice Benefit Private Insurance/Managed Care Medicaid Hospice Benefit Other Payment Source Self-Pay Charity or Uncompensated Care Who Pays for Hospice? National Hospice and Palliative Care Organization. (2014). Facts & figures: Hospice care in America. http://www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf
- 33. Reinforcing Hospice Facts If a patient chooses hospice, they will lose their physician. False. Hospice physicians and team members work with the patient's doctor or specialist to ensure clinical and emotional needs are being met and that the patient’s care is being carried out appropriately. The patient’s personal doctor chooses his or her level of participation in their care.
- 35. Four Levels of Hospice Care 1. Routine home care 98.2% – Most common level of hospice care – Patient’s preferred setting 2. Intensive Comfort Care® (continuous care) 0.2% – Medical management in the home for up to 24 hours per day for acute symptom management when medically appropriate National Hospice and Palliative Care Organization. (2020). Facts & figures: Hospice care in America. https://www.nhpco.org/factsfigures/ 3. Inpatient care 1.2% – For symptoms that cannot be managed in the home 4. Respite care 0.3% – Provides a temporary break for primary caregiver – Inpatient setting – Up to 5 days of 24-hour patient care
- 36. Bereavement • Hospice provides bereavement services and offers grief and loss support for the family after the patient dies. • For at least 1 year following a death, hospice provides: – Grief education resources, letters, cards – Phone/Telehealth support and/or visits if needed or requested by family – Bereavement support groups – Annual memorial activities – Memory Bears
- 37. Reinforcing Hospice Facts If a patient chooses hospice, they are obligated to stay on service. False. Hospice is a choice. • Once a patient is on hospice, they can revoke their hospice status at any time for any reason. • Patients can choose to return to hospice so long as they meet eligibility guidelines.
- 38. Advance Directives: Defined Advance directives are legal documents that allow patients to formally state their choices regarding what actions should be taken or not taken regarding their health in case they are no longer able to make decisions for themselves because of illness or incapacity.
- 39. Advance Directives • Studies show patients who had prepared advance directives received care that was strongly associated with their preferences. • In 1990, Congress enacted the Patient Self- Determination Act, mandating that all healthcare providers who receive Medicare and Medicaid funds must provide information regarding advance directives to patients admitted to their programs. • Advanced directives define the medical care a patient wants or does not want to receive if he or she becomes terminally ill and is mentally or physically unable to communicate his or her wishes. • Advance directives include living wills, durable power of attorney, and designation of a healthcare surrogate. Silveira, M., et al. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211-1218.
- 40. Reinforcing Hospice Facts A patient must have a do-not-resuscitate (DNR) order to receive hospice services. False. A patient is not required to have a DNR when enrolling in a hospice program. The hospice will, however, engage in goals- of-care conversations with a patient and family to align care goals with the hospice philosophy of a peaceful passing at home.
- 41. Advance Directives and Hospice • Patients are not required to have advance directives in order to receive hospice care. • Hospice staff will discuss the importance of advance directives for preserving and honoring patient choice. • Hospice offers training on advance directives. Advance directives preserve patient choice!
- 42. Hospice Impact: Satisfaction • Hospice care is associated with better symptom relief, patient-goal attainment, and quality of EOL care. • Families of patients enrolled in hospice more often reported that patients received “just the right amount” of pain medicine to help with dyspnea. • Families of patients enrolled in hospice also more often reported that patients’ EOL wishes were followed and they received “excellent” quality EOL care. • Families of patients who received > 30 days of hospice care reported the highest-quality EOL outcomes. Kelley, A., et al. (2013). Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Affairs, 32(3), 552-561.
- 43. Conclusion • Hospice is: – A service, not a place – Provided anywhere a person calls home – Care that comforts and supports when an advanced illness no longer responds to cure-oriented treatments – Making the most of the time that remains – Covered by the Medicare hospice benefit and most insurers
- 44. Partner With Hospice “You matter because you are you. You matter to the last moment of life, and we will do all we can, not only to help you die peacefully, but also to live until you die.” —Dame Cicely Saunders St. Christopher’s Hospice, London, England
- 45. References Arias, E. (2003). United States Life Tables, 2003. US Centers for Disease Control and Prevention, National VITAL Statistics Reports, 54:14. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf Cherny, N., et al. (2015). Oxford textbook of palliative medicine (5th ed.). Oxford University Press. Connor, S., et al. (2007). Comparing hospice and nonhospice patient survival among patients who die within a three-year window. Journal of Pain and Symptom Management, 33(3), 238-246. Emanuel, L., et al. (2003). The Education in Palliative and End-of-Life Care Curriculum (EPEC Project). Northwestern University Feinberg School of Medicine. Fulmer, T., et al. (2018). Physicians' Views on Advance Care Planning and End-of-Life Care Conversations. Journal of the American Geriatrics Society, 66(6), 1201-1205. Kelley, A., et al. (2013). Hospice enrollment saves money for Medicare and improves care quality across a number of different lengths-of-stay. Health Affairs, 32(3), 552-561. Lunney, J., et al. (2018). Mobile trajectories at the end of life: Comparing clinical condition and latent class approaches. Journal of the American Geriatrics Society, 66(3): 503-508. doi: 10.1111/jgs.15224.
- 46. References National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures National Hospice and Palliative Care Organization. (2014). Facts & figures: Hospice care in America. http://www.nhpco.org/sites/default/files/public/ Statistics_Research/2014_Facts_Figures.pdf Silveira, M., et al. (2010). Advance directives and outcomes of surrogate decision making before death. New England Journal of Medicine, 362(13), 1211-1218. United States Census Bureau. (2017). Facts for Features: Older Americans Month, May 2017. Retrieved from: https://www.census.gov/newsroom/ facts-for-features/2017/cb17-ff08.html Werner, C. (2011). The Older Population: 2010 US Census Bureau. Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf Xu, J. (2016). Percentage Distribution of Deaths, by Place of Death-United States, 2000-2014. US Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a6.htm Xu, J., et al. (2020). Mortality in the United States, 2018. NCHS Data Brief, January 2020. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db355.htm