Hospice and Bereavement

1
Hospice and Bereavement
CARING THROUGH THE END Palliative Care Along
the Continuum of CKD

• Carla Braveman, BSN, RN, M.Ed, CHCE
• VNA Hospice of Cooley Dickinson

2
Objectives

• Review hospice and the Medicare Benefit
• Describe the appropriate use of the Medicare
  Hospice Benefit with ESRD patients
• Describe the benefits to the family with hospice
  bereavement services after the death

3
What Is Hospice?

• Program of care for terminal patients
• Limited life expectancy
• Goals of care are comfort and not life prolonging
• In home, hospital, nursing home, rest home, etc

4
What Is Palliative Care?

• Not all palliative care is hospice
• Many hospice programs also have palliative care
  programs

5
Medicare Hospice

• Life expectancy of 6 months or less if the
  illness runs its normal course, based on the
  clinical judgment of the physician
• Services are consistent with the plan of care ,
  reasonable and necessary for the palliation or
  management of the terminal illness
• First HMO model of care - pays/ provides for all
  related medical care within the plan of care,
  excluding primary MD

6
Medicare Hospice Services

• Medications
• Treatments
• Medical Equipment
• Hospitalization, Outpatient Services
• Ambulance
• Respite care
• Bereavement
• Consulting Physician Services
• Staff RN, SW, Pastoral, Aides, Volunteers, MD
• related to the terminal condition and in the
  hospice plan of care

7
Renal Palliative Care Initiative

• 175 deaths in 2000
• 12 cared for by hospice at the time of death
• Plan
• Education for clinic and hospice staff
• Education for physician for non-renal diagnosis
• Results initial increase of referrals for 6
  months, then return to previous level

8
Hospice And ESRD Patients

• 70,000 ESRD patients die each year
• 10 to 20 of ESRD patients discontinue dialysis
  and die
• When ESRD is not the hospice diagnosis
• When ESRD is the diagnosis

9
Non ESRD Diagnosis

• Hospice diagnosis is not related to reasons for
  dialysis ex cancer, dementia
• LMRPs Local Medical Review Policies
• Documented decline and functional status
• See handouts
• Patient continues on dialysis and all related
  interventions outside of hospice
• Requires coordination of care

10
LMRP Example

• GENERAL DECLINE
• Increased dependence in at least 3 ADLs bathing,
  eating, dressing, walking, toileting
• Multiple co-morbidities
• Unintentional weight loss
• Increasing need for medical care ER visits,
  hospitalization, MD visits, transfers

11
LMRP Example

• END-STAGE LUNG DISEASE
• Presence of at least one characteristic of each
  category
• Disabling dyspnea, refractory to treatment
• Dyspnea at rest
• Dyspnea limiting a patient to a bed-to-chair
  existence
• Blood gas values consistent with end- stage
  disease
• PO2lt55 mm Hg on supplemental oxygen
• Oxygen saturationlt88 on supplemental oxygen
• PCO2gt50mm Hg
• Presence of right heart failure
• Physical findings of right-sided failure
• Echocardiographic documentation
• Cor pulmonale on EKG

12
ESRD Hospice Diagnosis

• LMRP region 1 abbreviated version
• A prognosis of less than 6 months is indicated by
  the presence of both of these characteristics in
  a patient not seeking a transplant or ongoing
  dialysis
• Creatinine clearance of less than 10ml/min
  (15ml/min in diabetes)
• Serum creatinine of greater than 8mg/dl (6mg/dl
  in diabetes)

13
Issues

• Dialysis not in the hospice plan of care
• Life prolonging
• Conflicts with ESRD LMRP
• Medicare will not pay for both dialysis and
  hospice for same diagnosis
• Focus Patients who have discontinued dialysis
• Lobby for possible Medicare demonstration
  project, payment for dialysis and hospice

14
Discontinue Dialysis

• 1-2 week prognosis
• At home, at nursing home, at hospital
• Add to standing orders hospice referral
• 100 of patients who stop dialysis should be
  offered hospice
• Provides additional support to patient and family

15
Benefits Of Hospice

• Staff support for center/ facility
• Improved patient communication and care planning
  and coordination
• Family support during death
• Pain and symptom management expertise
• Spiritual support making sense of the meaning
  of life and your place in it
• Counseling life review, anticipatory grief

16
Benefits Of Hospice

• Decreased hospitalizations (lt3 total days of
  care all patients)
• Improved clinical outcomes (GAO study)
• ? falls, hospitalization, restraints, feeding
  tubes, hyperalimentation
• ? treatment for pain, dyspnea, depression,
  anxiety
• Bereavement for family for 12 months to promote
  normal grieving

17
Benefits of Hospice

• Memorial service at clinics/ facilities
• Education about
• Ethical issues in end-of-life care
• Pain and symptom management
• Communication, listening
• Etc.

18
Contact Information

• Carla Braveman
• Executive Director
• VNA Hospice of Cooley Dickinson
• 168 Industrial drive
• Northampton, MA 01060
• 413-582-5301
• Carla_braveman_at_cooley-dickinson.org

19
ATTACHMENTS

• Quick guide to LMRPs
• LMRP description

20
References

• General Accounting Office/ Department of Health
  and Human Services, Outcomes and Utilization for
  Hospice and Non-Hospice Nursing Facility
  Decedents, http//aspe.os.dhhs.gov/daltcp/reports/
  oututil.htm
• www.lmrp.net - then go to your FI