Transcript Culturosity: Cultural Awareness in End-of-Life Care - CT-CMSA

Hospice Basics and Benefits
Goal
 To educate nurses and other health care
professionals about hospice basics and
the benefits for the patient and family.
Objectives
 Describe the history/philosophy of hospice
 List two or more criteria used to identify the
hospice appropriate patient and some common
diseases seen in end-of-life care
 Identify difference between curative and
palliative care
 Explain Medicare Reimbursement for hospice
 Discuss the relevance of advance directives
and DNR when discussing hospice services
All of Us Will Die
 <10% suddenly, unexpected event, heart
attach (MI), accident, etc…
 >90% protracted life-threatening illness
• Predictable steady decline with a relatively short
“terminal” phase (cancer).
• Slow decline punctuated by periodic crises (CHF,
emphysema, Alzheimer’s)
Dying in the 19th Century
 3% of America’s population was >65
 Life expectancy was 45-50 years
 Most people died at home
Dying in the United States Today
 13% of the population is > 65 years
 Approximately 75% of Americans die in
health care facilities
• 57% die in hospitals
• 17% die in long
term care facilities
Care at the End-of-Life
 Q: Where would you prefer to receive
medical care if you were terminally ill with
a prognosis of 6 months or less?
 A: 9 out of 10 respondents cite their home
as the preferred site of care.
History of Hospice
 Linguistic root words
•Hospital
•Hospitality
•Shelter
•Respite
•Caring
 A place of refuge and solace
Hospice History: U.K.
 1905 St. Joseph’s Sisters of Charity in
London
 1967 St. Christopher’s in London
 “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.”
 -Cicely Saunders
Hospice History: U.S.
 1969 Elizabeth Kubler-Ross’ “On Death and
Dying”
• Brought death and dying into mainstream
 1974 New Haven Hospice of Connecticut
 1976 VITAS beginnings
 1978 National Hospice Organization
• National Hospice & Palliative Care Organization now
• Mission - to lead and mobilize social change for
improved care at the end of life
VITAS’ Beginnings
 Available for ALL in the location of their choice, 24
hours a day, 7 days a week, for whomever needs it
regardless of race, religion, and/or inability to pay
 clients and families can and will teach us what they
need and determine their plan of care
 The Interdisciplinary group provides care with the
integration of medical, psychological and spiritual
services
 Staff efforts at the bedside should be supported and
coming to work should be a rewarding experience
What is Palliative Care?
“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’s Textbook of Palliative Medicine
Palliative Care ...
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Affirms life
Regards dying as a normal process
Neither hastens nor postpones death
Provides relief from pain and other symptoms
Integrates the psychological & spiritual aspects of care
Provides support for patient and family
World Health Organization
Curative vs. Palliative Care
 Curative
•Disease driven
•Doctor in charge
•Disease process is
primary
•Few choices
 Palliative
•Symptom driven
•Patient is in charge
•Disease process is
secondary to person
•Many choices
•Comfort & quality of life
Patient Appropriateness
 Life-limiting illness
 Medicare regulations
•Six months or less prognosis
•Two physicians
 Patient and/or family request
Oncology (Cancer) Diagnoses
 Breast CA
 Lung CA
 Bone CA
 Colon CA
 Renal Cell CA
 Advanced Prostate
 Pancreatic CA
CA with metastasis
 Bladder CA
 Malignant
Melanoma
 Head & Neck CA
Non-Oncology Diagnoses
 End Stage
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Cardiac
Pulmonary
Alzheimer’s Disease
Renal Disease
Liver
Stroke (Acute & Chronic)
ALS (Lou Gerhig’s disease)
 Debility Unspecified
 AIDS
Disease Progression
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Change or decline in performance status
Loss of appetite
Excessive weight loss
Difficulty breathing
Pain
End of Life Symptoms
 Unrelieved pain
 Confusion
 Restlessness
 Weight loss
 Shortness of breath
 Disturbed bladder and bowel function
 Disrupted sleep
 Nausea and/or vomiting
Pain and symptom management is the first priority!
End of Life Symptoms
 Psychosocial
•Depression
•Anxiety
•Ineffective coping and communication
•Life role transition
•Caregiver distress
 Spiritual
•Despair / hopelessness / isolation
•Powerlessness
•Loneliness
•Need for reconciliation
After the End-of-Life
 Hospice provides care for the family after the
patient dies via bereavement services
 For at least one year following a death,
hospice provides:
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Letters, cards
Phone calls (visits)
Bereavement support groups
Annual memorial services
Memory Bears
Hospice Interdisciplinary Team
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Patient and Family
Attending Physician
Hospice Physician / Medical Director
Registered Nurse
Hospice Aide
Social Worker
Chaplain
Volunteer
Medicare Hospice Benefit
 Passed by Congress in 1982
 Covers 100% of costs related to the terminal
diagnosis
• Includes HME
• Pharmacy
 Unlimited benefit periods
 Services are primarily reimbursed on a per
diem basis
Medicare Covered Services
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Skilled nursing services
Physician visits
Home health aide visits
Volunteer services
Medical social services
Spiritual counseling
Nutrition counseling
Bereavement support
for family
All services are provided based on the needs of the
patient and family!
Four Levels of Hospice Care
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Routine Home Care
Continuous Care
Inpatient Care
Respite Care
Ethical Issues
 Ethics Committees
 Advance Directives
 Do Not Resuscitate Order (DNR)
Advance Directives
 Includes living wills, durable power of attorney,
and health care surrogacy
 Define the medical care a patient wants or
does not want to receive if they become
terminally ill and are mentally or physically
unable to communicate their wishes
• In 1990, Congress enacted the Patient Self
Determination Act: all healthcare providers who
receive Medicare and Medicaid funds must
provide information regarding Advance Directives
to patients admitted to their program
Hospice & Advance Directives
 Patients do not have to have advance
directives in order to receive hospice care
 Hospice staff will discuss the importance of
advance directives in preserving patient choice
 Hospice offers training on advance directives
Advance Directives Preserve Patient Choice!
Do Not Resuscitate Orders (DNR)
 DNRs communicate a patient’s wishes
regarding the use of cardio-pulmonary
resuscitation
 Patients are not required to sign a DNR in
order to elect or receive hospice care
Partner with Hospice
 Benefit from hospice’s rich history
 Know criteria used to identify the hospice
appropriate patient
 Ask: could the patient’s quality of life be better
served by palliative care vs. curative care?
 Medicare Hospice Benefit covers 100% of the
costs related to the terminal diagnosis
 Hospice educates patients/families on advance
directives and DNRs
“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
References
Ferrell, B., & Coyle, N. (2008). The Nature of Suffering and the Goals of Nursing.
Oxford: Oxford University Press.
Ferrell, B., & Coyle, N. (Eds.). (2010). Textbook of Palliative Nursing (3rd ed.).
Oxford: Oxford University Press.
Kinzbrunner, B., & Policzer, J. (Eds.). (2011). End-of-Life Care A Practical Guide
(2nd ed.). New York: McGraw Hill Medical
Kuebler, K., Berry, P., & Heidrich, D. (2002). End-of-Life-Care Clinical Practice
Guidelines. Philadelphia: Saunders.
Matzo, M., & Sherman, D. (Eds.). (2001). Palliative Care Nursing Quality care to the
end of life. New York: Springer Publishing Company.
Office, E. P. (2010). End of Life Nursing Education Consortium. Paper presented at
the ELNEC Train the Trainer, Washington DC.
Organization, NHPCO. (2012). Hospice Information. Caring Connections Retrieved
01/03/2012, 2012, from http://www.nhpco.org/i4a/pages/index.cfm?pageID=3254
Puchalski, C., & Ferrell, B. (2010). Making Health Care Whole Integrating Spirituality
into Patient Care. West Conshohocken, PA: Templeton Press.
Hospice Basics and Benefits