Transcript THE CENTER FOR EXCELLENCE IN END-OF

HOSPICE:
OPTIMIZING PALLIATIVE CARE
FOR
PATIENTS WITH ESRD
Judith A. Skretny, M.A.
The Center for Hospice & Palliative Care
Buffalo, New York
We have been challenged by the
RWJF ESRD Workgroup
The Challenge
•Collaboration
•Education
•New and Innovative Models of Care
What is Hospice?
Is it similar to or different from
Palliative Care?
Hospice
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A Philosophy
A Program
A Facility
A Benefit
Hospice Philosophy
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Palliative care for terminally ill patients
and their families
Control of distressing physical
symptoms, psychological and spiritual
support, and bereavement care
Interdisciplinary team of professionals
and volunteers
Primary Hospice Services
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Physical symptom control-pain, nausea,
dyspnea, etc.
HHA services-bathing, dressing, feeding
Psychosocial counseling-patient and family
Spiritual support-patient and family
Completion of advance directives, wills,
funeral planning
Volunteers
Bereavement services
The Interdisciplinary Team
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Hospice medical director
Skilled nursing
Social work
Pastoral care
Home health aides
Volunteers
Bereavement programs
Where Can Hospice Services
Can Be Received?
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Home
Hospital
Nursing Home
In-Patient Units
The Hospice Benefit Includes:
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All drugs related to terminal illness
All durable medical equipment
Therapies: OT, PT, music, massage, dietary
Other services as approved in plan of care:
radiation, chemoRx, TPN, Tx, hydration,
surgery
Hospice receives approx. $106/day to provide
these services
Eligibility for Hospice Care
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MD certified prognosis <6 mos. If
disease pursues its usual course
Any terminal diagnosis is appropriate
Treatment goals are palliative rather
than “curative”
No therapy excluded pro forma
No DNR required
Medicare Hospice Benefit
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Elect Hospice benefit for terminal
illness, sign off Medicare A (hospital)
PMD may remain primary, bills Part B
Benefit periods/90/90/60….days
Patient recertified as hospice eligible at
beginning of each benefit period …
unlimited recertifications
Patient may revoke at any time
Myths: Hospice doesn’t “admit”
patients who
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Don’t have cancer
Don’t have a DNR
Are receiving tube feedings or TPN or
IVs
Are receiving chemotherapy or radiation
therapy
Need palliative surgery
Don’t have a primary caregiver
Unfortunate Reality:
Patients with ESRD who continue
to receive dialysis cannot
access their hospice benefit.
Hospice
Interdisiciplinary, compassionate,
competent end-of-life care that aims to
relieve suffering and promote QOL for
patients and their families
Palliative Care and Hospice
A hospice program provides palliative
care and supportive services to
terminally ill patients, their families and
significant others throughout the course
of the illness and into bereavement.
Hospice is the
pre-eminent
practitioner of palliative
care
HOSPICE = PALLIATIVE CARE
PALLIATIVE CARE > HOSPICE
Palliative Care
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No specific therapy is excluded from
consideration. The test of palliative treatment
lies in the agreement…that the expected
outcome is relief from distressing symptoms,
easing of pain, and improvement in quality of
life.
 The decision to intervene is based on the
treatment’s ability to meet the stated goals,
rather than its effect on the underlying
disease.
Barriers to Hospice Referrals:
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Death Denying Society – “giving up”,
“hope”
Medicine is a death defying profession
Lack of training/information
Difficulty re: prognostication
Belief that Hospice is for the last days of
life
Opportunities for Collaboration
Hospices and Dialysis Units are Natural
Partners in Providing:
• End-of-life education for staff, patients,
families
• Advance care planning seminars for
patients and families
• Seminars for staff, patients and families
on anticipatory grief, spirituality
Hospices can assist dialysis units by
providing:
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Training in having “difficult”
conversations
Support groups for staff of dialysis units
Information on how to discuss Hospice
as part of care planning
Direction on developing bereavement
services
Hospices can assist the medical
community by providing:
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Rotation opportunities for nephrologists
Medical student education
University affiliated training for social
workers, PT, OT, nurses, potential
nephrology specialists
When the decision has been made to
stop dialysis:
Hospices and Dialysis Units can create a seamless
referral process into Hospice that ensures the:
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Same physician will follow the patient
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The process of admission is simple
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Possible scenarios are anticipated and discussed
i.e. dyspnea, seizures
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The patient and family are supported
psychologically and spiritually
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Children in the family will receive support from child
life specialists
Innovative Programs
VNA & Hospice of Cooley-Dickinson
Northampton, MA
Self-Determined Life Closure
The Death of Ivan Ilyich – Tolstoy
 “What tormented Ivan Ilyich most was
the deception, the lie…that he was not
dying but was simply ill, and that he only
need keep quiet and undergo treatment
and then something very good would
result.”