Transcript Introduction to End of Life Care: Achieving a Good Death

Introduction to Hospice and
Palliative Medicine
Bansari Patel, APN, ANP
Joan Bigane, APN, FNP
University of Chicago Medical Center
Case Study
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Mr. H is a 77 y/o AAM with history of Stage 4 Nonsmall 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 ?”
Case Study
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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?”
Hospice Experience Model
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Physical Dimension (perceived distress/discomfort)
Functional Dimension (perceived ability to perform ADLs and
IADLs)
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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
General Principles of Hospice
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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
Hospice Q&A
Mr. H asks you “What services will hospice
provide me home?”
Nursing
Physician
Social Worker
Spiritual Support
Homemaker
PT/OT/ST
Trained volunteers
Respite
Bereavement Support
CAM
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?”
History of the Hospice Movement
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Evolving since the 11th century
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The hospice movement in the United States has its roots in the work of British
physician Dame Cicely Saunders and Dr. Elisabeth Kubler-Ross.
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In 1967:,Dr. Saunders founded the first modern hospice -- St. Christopher's
Hospice in London, England.
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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
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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.
History of the Hospice Movement
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Early 1980s, Congress created legislation establishing Medicare coverage
for hospice care. The Medicare Hospice Benefit was made permanent in
1986. Today most states also provide hospice Medicaid coverage.
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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
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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.
How are hospice services covered?
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Private Pay
Some insurances: BlueCross; Aetna; UCHP
Medicaid
Medicare Hospice Benefit
Case Study
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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.
Case Study
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The imaging shows stable metastatic disease.
You increase her opioids and bring up the
idea of having a palliative medicine team
consult.
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?”
Palliative Care Services
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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
History of Palliative Care
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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
Reimbursement
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Medicaid
Private Insurance
Out of pocket
Grants
Not Medicare, per se
Benefits of Hospice/Palliative Care
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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
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