Hospice and Palliative Care: An Overview

Patrick J. Macmillan, MD, FACP Division of Palliative Medicine Department of Internal Medicine East Tennessee State University James H. Quillen College of Medicine

Introduction

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What is Palliative and Hospice Medicine?

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Disease that are most frequently seen

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Hospice guidelines

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Evidence for Palliative and Hospice Care

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Resources

Philosophy

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Emphasize advanced planning and ongoing care and support rather than crisis intervention

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Promotion of psychosocial and spiritual growth and development

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No specific therapy is excluded—treatment is based, however, on meeting treatment goals rather than effect on underlying disease

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Radiation, chemotherapy, surgery are NOT excluded in palliative or hospice care

History: Western Civilization

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Earliest recorded hospice 475 in Rome

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Middle Ages: Christian religious orders in Europe

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Modern hospice movement: Irish sisters of charity 1879

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St. Christopher’s Hospice 1967 in London remains one of the preeminent hospice programs in the world

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First hospice program in US opened in 1974 in New Haven, CT

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1996 450,000 patients were served by 2,700 hospice programs

Alternatives

Quality of Life

Medical Ethics

Palliative Care

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Medical Care for people with serious illnesses—focuses on relief from symptoms and suffering

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Palliative medicine is 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.

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WHO: “active total care of patients whose disease are NOT responsive to curative treatments.”

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Is Palliative Care the same as Hospice?

Palliative Care

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NO—Hospice is a “focus” of Palliative Care targeted at the terminally ill

 Goals: Improve quality of life for family and patient 

Give patient a voice in Tx Plan

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Appropriate at any stage of serious illness

Palliative Care

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“Patient and Family centered care that optimizes quality of life by anticipating, preventing and treating suffering.

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A continuum of treatment that focuses on all aspects of a person

NQF National Framework and Preferred Practices for Palliative and Hospice Care

Palliative Care

 Referral: complications, uncontrolled symptoms, multiple

comorbidities, and patient or family distress

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Assistance needed for complicated decision-making

Palliative Medicine

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Lancet September 2010; Double-blind, randomized controlled trial

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Study comparing Palliative O2 vs. Intranasal room air

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239 patients, life-limiting illness, refractory dyspnea and PaO2>55

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Each group received either O2 or room air at 2L/min NC

 Conclusion: No significant difference in rating of dyspnea; air

movement across the face (hand held fan) helps relieve dyspnea

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Oxygen is costly and risky for some patients

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Simple interventions can be used in case where there is NOT true hypoxia

Hospice Care

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Hospice Care: 6 months or less to live IF disease runs its natural course. (Also need family consent)

Hospice Care

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Cancer, COPD, Heart disease, ESRD, ESLD, Dementia, CVA, AFTT, Debility, AIDS

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NHO (National Hospice Organization) medical guidelines

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Cancer: Cancer plus metastasis (clinical findings) with widespread aggressive and progressive disease

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PPS score of < 70%

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Patient refusing further Tx

Hospice Care

 COPD: Severe and progressive lung disease 

FEV1<30% predicted

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ER visits or hospitalization for lung infections

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Hypoxemia at rest (o2 sat<88%)

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Hypercapnea (Pco2 >50 mm Hg)

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Best indicator is FEV1

Hospice Care

 Heart Failure 

New York Heart Association Class IV (Sxs at rest)

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Optimal Tx

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Other: refractory arrhythmias, hx of cardiac arrest, syncope

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Can be on transplant list

Hospice Care

 Dementia 

Severe Dementia and 1 st complications occurrence of medical

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Severity: unable to ambulate independently, no meaningful conversation, urinary/fecal incontinence, unable to dress/bathe independently. “total care”

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Medical complications: UTI’s, aspiration PNA, wt loss, etc.

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Documentation of rapid decline

Hospice Care

 HIV Disease 

CD4 count<25

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Viral Load >100K copies/mL

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Decreased functional status

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Other: CNS Lymphoma, PML, wasting, MAC bacteremia, refractory Toxoplasmosis

 Note: 80% HIV patients alive 10 years after seroconversion

Hospice Care

 End-stage liver disease 

INR>1.5 and Albumin <2.5 gm/dl

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Clinical syndromes: Ascites in spite of diuretics, SBP, Hepatorenal syndrome, Hepatoencephalopathy despite lactulose

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Recurrent variceal bleed

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Other: active etoh abuse, Hep B, CA, malnutrition

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Note: Patients can be on hospice pending liver transplants

Hospice Care

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End-stage renal disease

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No dialysis

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Lab criteria: creatinine >8.0 and clearance <10

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Others: CVA, coma, ALS, MS, Parkinson’s disease, AFTT, debility

Hospice/Palliative Care

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90% of Americans die after living with a chronic, progressive incurable illness

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1/3 of healthcare costs occur in last year of life

 Duke University Study (2007): hospice saves Medicare an average

of more than $2,300 for each hospice beneficiary

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Reduction in Medicare costs if hospice recipients been on for a longer period

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Hospice patients lived an average of 29 days longer than those not referred to hospice

Hospice/Palliative Care

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Study: 228 ambulatory patients with newly diagnosed non small cell lung cancer

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Standard oncologic care vs. palliative care

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Palliative care group survived longer (11.6 months vs. 8.9 months)

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Analysis (included age and performance status) showed early palliative care was an independent predictor of survival

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Subgroup (107 patients in both groups) survived to 12 weeks— PC group reported better quality of life

Hospice/Palliative Care

 Palliative care group received less chemo 

Made fewer ER visits

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More likely to die at home

Resource Use in the Last 6 Months of Life Among Medicare Beneficiaries With Heart Failure, 2000-2007

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Archives of Internal Medicine: Retrospective cohort study: February 14, 2011

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US patients, 200,000 Medicare beneficiaries who died in 2000-2007

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Use of hospice increased from 19% to 40% over the course of the study

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Average number of days in ICU increased

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80% of patients were hospitalized in last 6 months of life

Hospice/Palliative Care

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Assessed length of patients stay in hospice

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19% stayed < 3 days, 37% < 1 week

Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer

 Archives of Internal Medicine: Retrospective cohort study 2011 

Hospice use among men dying of Prostate CA between 1992-2005

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53% used hospice—22% of this group enrolled in hospice < 1 week

 Conclusion: “short stays [in hospice] don’t allow patients

to receive full benefits of enrollment in hospice.”

Hospice/Palliative Care

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Study did find an increase in use of hospice care over time

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Hospice patients less likely to receive high-intensity care

 Conclusion: “Increasing the appropriate use of hospice care

for patients at end of life could both improve quality of death and reduce ineffective health care expenditures.”

Hospice/Palliative Care

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Late referrals are due partly to physicians attitudes about death

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May view patients death as a medical or personal failure

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May feel they have nothing else to offer when curative goals are exhausted

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Distance themselves from patients and families because uncomfortable talking about death

Hospice/Palliative Care

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Prognosis-related issues also problematic

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Accurately predicting prognosis is difficult (particularly non-cancer diagnosis)

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Best Prognosticators: length of practice, subspecialists

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If you have known the patient a long time---less accurate

Hospice/Palliative Care

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The Good News

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Changes in attitudes regarding advanced diseases and improving quality of life

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More acceptance of Palliative care concept

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Access to palliative care improving

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Curriculum changes in medical school