Hospice and Palliative Care Objectives

Hospice and Palliative Care Objectives

• Identify factors impacting life expectancy estimations.
• Locate resources aiding prognostication for older adults.
• Differentiate between palliative and curative care.
• List hospice care benefits and barriers.
• Describe hospice funding mechanisms.
• Explain patient referrals and hospice admission criteria.
• Discuss roles within interprofessional end-of-life care teams.
• Evaluate prognostication concepts.
• Apply prognostication components in end-of-life care.
• Evaluate prognostication's impact on patients, caregivers, and providers.

Definitions

• Hospice care: A comprehensive comfort-focused system for those expected to live ≤6 months. Its sole focus is comfort and relief of suffering for individuals at life's end.
• Palliative care: Interdisciplinary care aiming for suffering relief, improved quality of life, and decision support for individuals with advanced illnesses.

Goals of Care

• Palliative Care: Alleviates uncontrolled symptoms (pain, existential). Can be combined with curative or comfort care.
• Hospice Care: Provides comfort at end-of-life; not curative.

Hospice Criteria

• Life expectancy of less than six months, agreed upon by two providers (usually the referring provider and hospice director).
• Some hospices require patients no longer pursue life-extending interventions (though some do not, and the VA does not).
• Clinical documentation validating the criteria is essential.
• Medicare LCD guidelines offer disease-specific criteria for hospice eligibility.

Hospice Settings

• Home: Ideal for remaining at home with loved ones.
• Facility: Assisted living or nursing homes (if family unable to manage symptoms at home; no inpatient needs).
• Inpatient: For severe, uncontrolled symptoms not manageable at home, or if inpatient safety concerns exist.

Hospice Team

• Physician (medical director).
• Registered nurses.
• CNAs (for ADLs).
• Social workers.
• Volunteers.
• Bereavement specialist.
• Chaplain (often a bereavement specialist; and may not always be a bereavement specialist).

Palliative Settings

• Outpatient: Clinic-based, for discussions on end-of-life/symptom management (pain, nausea, constipation, etc.). Repeated clinic visits are common.
• Inpatient: Hospital-based, addressing current circumstances (with follow-up in outpatient setting if appropriate). Discussions often centered on current symptoms and conditions.

Palliative Team

• Physicians/advanced practice providers (APPS).
• Registered nurses.
• Medical assistants (MAs).
• Social workers (often).
• Chaplains (often, especially inpatient).

Hospice: Medicare Benefit

• Six-month prognosis, certified by two physicians; patients can revoke.
• Regular recertification for hospice eligibility, essential with clear documentation; this must show life expectancy of less than 6 months.
• Patients forgo curative treatments, and the care plan is managed by hospice.
• Treatment continuation may be allowed in some hospices ('open access').

Bereavement

• Hospice benefit includes bereavement care.
• Support continues for at least one year after the patient's death, typically past first anniversary plus one month; support varies, often including follow-ups, office visits, home visits, and support groups.

Palliative Medicine (End-of-Life)

• Extended visits to discuss disease progression, prognosis, and grief management (symptom control for comfort).
• Can be given alongside hospice care.
• Inpatient discussions with families and the care team focus on impending death and associated symptoms.

Palliative Care (Hard Decisions)

• Inpatient consultations for complex decision-making (e.g., surgery vs. medical treatment, curative vs. comfort care, code status).
• Including decisions on end-of-life options (VCE&D, medical aid in dying).

Palliative Care (Symptom Control)

• Symptom management when other therapies fail to achieve benefit (pain, nausea, constipation, diarrhea, side effects, breathlessness, fatigue).

Existential Dread

• Psychological turmoil facing imminent death.
• Impacts physical, personal, relational, spiritual, and religious well-being.
• Can exacerbate physical/psychological symptoms.

Summary

• Hospice eligibility criteria, funding, and settings.
• Palliative care approaches and goals.
• Teams and their functions in both hospice and palliative care.
• Ethical considerations (prognosis, difficult decisions, etc.).

Prognostication

• Importance of accurate discussions (no negative impact on hope and coping)
• Practitioners' challenges in prognostication (uncertainty, potential errors, bias).

Prognostication Tools

• Palliative Performance Scale: Assessing self-care and function.
• Eprognosis: Validated prognostic indices for clinical use.
• Hospice in a minute: Smartphone app for hospice criteria.
• Clinical judgment also vital: (e.g., aneurysm, cardiac arrest).
• Specific tools are for various illnesses and should be used appropriately.

Prognostication for Normal Life Expectancy

• Data tables illustrating how life expectancy varies by age/gender quartile.

Clinical Choices

• Deciding whether to continue screening/monitoring based on 10-year life expectancy.

Delivering Bad News, Strategies

• Start by inquiring about patient/family understanding of situation.
• Use a "warning shot" approach.
• Consider patient/family emotional needs.
• Answer questions & address any emotional needs/mood disorders that may arise. Use native language for effective communication.

Asking Before Giving

• Consider asking how the patient prefers to receive information.
• Allow for possible involvement of loved ones—but check with patient first.

Family Dynamics

• Importance of assessing family involvement in care decisions.
• Addressing any potential conflicts about support roles for the patient.

Follow-up

• Planning for follow-up visits, addressing concerns, and coordinating care.
• Including referrals, tests, and/or support resources. (Follow-up may not always be about end-of-life decisions.)

Having Talks about End-of-Life

• Initiating conversations when decisions aren't urgent for better planning.
• Focusing on the patient’s priorities and what a "good death" means to them.

Advanced Care Planning

• POLST: Physician Orders for Life-Sustaining Treatment – guiding medical choices across settings.
• Research suggests that POLST use reduces unwanted hospitalizations.
• Alternative end-of-life options: Medical Aid in Dying (may involve medication to end life sooner if prognosis is less than 6 months) and is legal in 10 states including NM and Washington DC. Competent patients can make a decision to end their lives. Physicians, advanced practice providers, (PA/NP), can prescribe the medication.