Assessment and management of pain near the end of life

1
Assessment and management of pain near the end of
life

• David Casarett MD MA
• University of Pennsylvania

2
Goal

• To describe an evidence-based approach to pain
  management near the end of life, with a focus on
• Assessment
• Defining goals for care and enpoints of pain
  management
• Use of opioids
• Appropriate use of opioids
• Managing opioid-related side effects
• Beyond pain management the role of hospice in
  long term care

3
Audience

• Clinicians in long term care
• Physicians
• RNs
• Advance Practice Nurses
• Surveyors
• Quality Improvement leaders

4
Case

• Mr. Palmer is an 84 year old man with moderate
  dementia (MMSE15), severe peripheral vascular
  disease and coronary artery disease.
• He currently lives in a nursing home, where he
  is dependent on others for most activities of
  daily living. He is able to speak in short
  sentences and can participate in health care
  decisions in a limited way. His daughter
  discusses his care with him, but ultimately makes
  all decisions for him.

5
Case, part 2

• He suffers a fall that results in a fracture of
  the left hip and is evaluated in a hospital
  emergency room.
• Because of his other medical conditions, high
  operative risk, and poor quality of life, his
  daughter decides with Mr. Palmer that he would
  not want to undergo surgery and instead would
  prefer to be kept comfortable.
• He returns to the nursing home with a plan for
  comfort care, with an emphasis on pain
  management.

6
Outline

• Scope of the problem pain near the end of life
  in nursing homes
• Assessment
• Background
• Principles of assessment
• Management
• Establishing goals of care
• Defining endpoints of pain management
• Opioids-the mainstay of pain management near the
  end of life
• Use of opioids
• Management of side effects
• Beyond pain management the role of hospice in
  the nursing home

7
Scope of the problem pain near the end of life
in nursing homes

• Defining the end of life
• No established definition
• 6 month prognosis (hospice eligibility) not
  useful
• Arbitrary
• Difficult to determine accurately
• Instead A resident is near the end of life if
  he/she has a serious illness that is likely to
  result in death in the foreseeable future
• Operationalize as Would I be surprised if this
  resident were to die in the next year? (Joanne
  Lynn)
• Mr. Palmer Would not be surprisedperipheral
  vascular disease, coronary artery disease,
  dementia, recent hip fracture.

8
Scope of the problem Common serious illnesses in
the nursing home

• Cancer
• Dementia
• Stroke
• Peripheral Vascular Disease
• Falls/Hip fracture
• Congestive Heart Failure
• Chronic Obstructive Pulmonary Disease
• Cirrhosis
• Associated with pain

9
Prevalence of pain (all diagnoses)

• Depends
• Surveys 30-71
• Medication audits 25-50
• Hospice (Pain requiring intervention)
• 25 (Casarett 2001)

10
What is the primary cause of pain?

• Low back pain 40
• Previous fractures 14
• Neuropathy 11
• Leg cramps 9
• DJD (knee) 9
• Malignancy 3 (Ferrell et al JAGS
  1990)

11
What are the characteristics of pain in the
nursing home?
(Ferrell et al JAGS 1990)
12
Room for improvement?

• Undetected in 1/3 (Sengstaken and King 1993)
• Undertreated (Bernabei et al 1998)
• Both (cognitively impaired) (Horgas and Tsai
  1998)

13
Pain assessment
Adapted from AGS Persistent Pain Guidelines
14
Comprehensive pain assessment History

• Evaluation of Present Pain Complaint
• Self-report
• Provider/family reports
• Impairments in physical and psychosocial function
• Attitudes and beliefs/knowledge
• Effectiveness of past pain-relieving treatments
• Satisfaction with current pain treatment/concerns

15
Comprehensive pain assessmentObjective data

• Careful exam of site, referral sites, common pain
  sites
• Observation of physical function
• Cognitive impairment
• Mood
• Limited role for imaging
• May be useful
• Often will not change management

16
Special situations Mild to moderate cognitive
impairment

• Direct query
• Surrogate report only if patient cannot reliably
  communicate
• Use terms synonymous with pain (hurt sore)
• Ensure understanding of tool use
• Give time to grasp task and respond and
  repetition
• Ask about present pain
• Ask about and observe verbal and nonverbal
  pain-related behaviors and changes in usual
  activities/functioning
• Use standard pain scale, if possible
• 0-10 Numeric Rating Scale
• Verbal Descriptor/Pain Thermometer
• Faces Pain Scale

17
Numeric Rating Scale

18
Verbal Descriptor Scales

• Verbal Descriptor Scale (VDS)
• ___ Most Intense Pain Imaginable
• ___ Very Severe Pain
• ___ Severe Pain
• ___ Moderate Pain
• ___ Mild Pain
• ___ Slight Pain
• ___ No Pain
• (Herr et al., 1998)

• Present Pain Inventory (PPI)
• 0 No pain
• 1 Mild
• 2 Discomforting
• 3 Distressing
• 4 Horrible
• 5 Excruciating
• (Melzack 1999)

19
Pain Thermometer
(Herr and Mobily, 1993)
20
Advantages of verbal descriptor scales

• Data suggest that patients may be more likely to
  be able complete verbal descriptor scales
  (Ferrell 1995Closs 2004)
• May be less sensitive to cognitive
  impairment/visual impairment
• But, no one size fits all scale

21
Facial Pain Scales
Faces Pain Scale
Bieri D et al. Pain. 199041139-150.
22
Principles of assessment mild/moderate cognitive
impairment

• The best assessment method is the one that the
  patient can use
• This is often, but not always, a verbal
  descriptor scale
• Use the same instrument/scale consistently
• Use it in the same way

23
Special situationsModerate to severe cognitive
impairment

• Direct observation or history for evidence of
  pain-related behaviors (during movement, not just
  at rest)
• Facial expressions of pain (grimacing)
• Less specific slight frown, rapid blinking,
  sad/frightened face, any distorted expression
• Vocalizations (crying, moaning, groaning)
• Less specific grunting, chanting, calling out,
  noisy breathing, asking for help
• Body movements (guarding)
• Less specific rigidity, tense posture,
  fidgeting, increased pacing, rocking, restricted
  movement, gait/mobility changes such as limping,
  resistance to moving

24
Moderate to severe cognitive impairment

• Unusual behavior should trigger assessment of
  pain as a potential cause
• Caveat Some patients exhibit little or no
  pain-related behaviors associated with severe
  pain
• Always consider whether basic comfort needs are
  being met
• Pre-test probability Evidence of pathology that
  may be causative (e.g. infection, constipation,
  fracture)?
• Attempt an analgesic trial
• If in doubt, analgesic trial may be diagnostic
• Acetaminophen 500mg TID, (titrate up to 3-4G/day)

25
Principles of assessment moderate/severe
cognitive impairment

• No single optimal method (no gold standard)
• Assessment requires several sources of
  information (observations of several providers,
  family)
• Many pain-related behaviors are non-specific
• If no known cause of pain, trial of acetaminophen
  can be useful
• If reason for pain, empirical treatment is
  appropriate

26
Pain management
27
Principles of pain management

• Defining goals of care
• Defining endpoints of pain management
• Opioids-the mainstay of pain management near the
  end of life
• Use of opioids
• Management of side effects
• Beyond pain management the role of hospice in
  the nursing home

28
Individualized care planningDefining goals of
care

• Highly variable goals for care
• Comfort
• Function
• Survival
• Highly variable preferences about specific
  management choices
• Site of care
• Treatment preferences (e.g. DNR, transfer to
  hospital)
• Site of death
• Optimal balance of pain, sedation, and other
  medication side effects

29
Treating pain in a resident with these goals.

• Cure of disease
• Maintenance or improvement in function
• Prolongation of life

30
Or treating pain in a resident with these goals.

• Relief of suffering
• Quality of life
• Staying in control
• A good death
• Support for families and loved ones

31
The importance of defining goals of care

• Cure of disease
• Maintenance or improvement in function
• Prolongation of life

• Relief of suffering
• Quality of life
• Staying in control
• A good death
• Support for families and loved ones

32
Individualized care planning2 examples

• Mr. Palmers daughter accepts that there are no
  further treatment options available to extend
  life. She says it is most important for her
  father to avoid pain or discomfort.
• Aggressive pain management
• Family support
• Hospice
• Mr. Palmers daughter says that he would want any
  treatment that might improve his survival and
  maintain the function he has left. She says he
  wants aggressive treatment even if it results in
  discomfort.
• Surgical intervention
• Aggressive physical therapy

33
Curative / Life-prolonging Therapy
Course of illness?
Relieve Suffering (Palliative Care and hospice)
34
Challenges of defining goals of care accurately

• Interpreting resident statements
• Multiple disciplinesmultiple interpretations
• (Importance of clear documentation)
• Conflicting resident/family goals
• Uncertainty about resident decision-making
  capacity
• Changes in goals over time (resident and family)
• Inconsistent preferences or goals (e.g. extending
  life but no transfer to acute care)

35
Defining goals of care principles

• Broad categories are most useful (survival,
  function, comfort, others that are
  resident-defined)
• Goals rather than treatment preferences (e.g.
  resuscitation status)
• Useful guides (not mutually exclusive)
• Prolonging survival
• Preserving function/independence
• Maximizing comfort

36
Case Goals for care

• Mr. Palmers daughter accepts that there are no
  further treatment options available to extend
  life. She says it is most important for her
  father to avoid pain or discomfort.
• This plan is communicated to other family members
  and staff, and is clearly documented in the
  medical record

37
Defining endpoints of pain management

• The optimal plan of pain management is one that
• Achieves an acceptable (to the patient) level of
  pain relief
• Preserves an acceptable level of alertness and
  function
• Offers an acceptable side effect profile

38
Defining endpoints of pain management

• Usually not no pain
• Depends on
• Goals
• Treatment preferences
• Tolerance for side effects

39
A note about assessing satisfaction

• Advantages
• Simple, easy to assess
• Easy to interpret
• Often encouraged by facility leadership
• Disadvantages
• Ceiling effect
• Poor association with pain control
• Confounded by other factors (Ward 1996, Desbiens
  1996, Casarett 2002, Gordon 1996)
• Side effects
• prn dosing/control
• Ethnicity
• Depression

40
Pain management near the end of life focus on
opioids
41
Multiple strategies for the management of pain
near the end of life

• Heat/cold
• TENS units
• Counseling
• Spiritual support
• NSAIDs/Acetaminophen
• Agents for neuropathic pain (e.g. tricyclic
  antidepressants, gabapentin)
• Opioids

42
Key principles of management

• Opioids are mainstay of management
• Use of multiple pharmacological agents is often
  needed to provide optimal management
• NSAIDs
• Tricyclic antidepressants
• Corticosteroids
• Anticonvulsants
• Traditional rules discouraging polypharmacy dont
  apply in this setting importance of
  individualized management.

43
Why focus on opioids?

• Highly effective
• Underutilized
• Poorly understood by providers and public
• Common misconceptions

44
Pain management near the end of life the role of
opioids

• The mainstay of effective pain management near
  the end of life
• Appropriate for residents with moderate or severe
  pain
• 4/10 or greater, or
• Conditions that are associated with
  moderate-severe pain (when resident is too
  cognitively impaired to permit an accurate
  assessment of severity)

45
Addiction and other concerns about opioids

• Addiction a syndrome of physical and
  psychological dependence
• Very rare in opioid treatment near the end of
  life
• Estimates of risk are ltlt1
• Except in very unusual circumstances (e.g.
  history of drug dependence), concerns about
  addiction are not appropriate in the setting of
  pain management near the end of life

46
Increases in opioid dose often attributed
(incorrectly) to addiction

• Tolerance Gradual decrease in sensitivity to
  opioid effects (pain relief and side effects)
• Results in dose creep
• Disease progression
• Pseudo addiction Increases in medication
  requests (particularly prn opioids) out of
  proportion to pain and/or medication hoarding, in
  the setting of significant discomfort
• Often labeled as addiction/diversion
• Much more likely to be due to fear of pain/slow
  nursing response to requests for prn meds/desire
  for more control over pain management
• Managed by more aggressive pain management not by
  reducing/controlling opioids

47
Using opioids strategies for administration

• Non-invasive (oral//PEG tube/transdermal)
  administration is preferred
• Sustained release preferred for persistent pain
• Virtually all patients receiving sustained
  release opioids should have prn opioid available
  for breakthrough pain (typically 10 of the 24
  SR dose)

48
Strategies for administration

• Begin with immediate release preparation
• Scheduled (cognitively impaired/severe pain)
• prn
• Can increase every 6-8 hours (faster if using
  IV/SC administration)
• Titrate up in reasonable (proportional) steps
  (think in terms of 20-50 increases)
• Switch to a long-acting preparation when pain
  control is adequate but continue access to prn
  dosing
• If continued titration is needed, use prn doses
  to estimate additional opioid requirements

49
Which opioid? Basic considerations

• Morphine Inexpensive, widely available, and can
  be administered by multiple routes and schedules
• Hydromorphone More potent, but no SR and limited
  routes of administration. Advantages in renal
  insufficiency.
• Oxycodone SR available, also concentrated PO,
  but no IV. Possibly decreased risk of delirium
  in older patients.
• Methadone inexpensive, available IV and PO.
  T1/2 is longer than duration of effect.
• Fentanyl patch Convenient, conversion difficult,
  poor choice when rapid titration is needed.

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Which opioid?

• Overall, no evidence of one agents superiority
  with respect to
• Effectiveness
• Side effects
• Choice based on
• Past experience
• Clinicians comfort/experience with an agent
• Specific features of a residents case (e.g. need
  for rapid titration)

51
Choosing an opioid in the setting of hepatic
failure

• Opioid metabolism
• Hepatic metabolism/conjugation
• Renal excretion
• Less desirable
• Codeine (Decreased conversion to morphine and
  decreased efficacy /- increased side effects)
• Methadone (decreased Phase I metabolism)
• Liver
• Gut metabolism and elimination (p-glycoprotein)
  (variable bioavailability in hepatic failure)
• Other (preferable) agents only have increased
  bioavailability
• Oxycodone (decreased Phase I metabolism)
• Morphine (decreased Phase II conjugation)
• Hydromorphone (decreased Phase II conjugation)
• Fentanyl (decreased Phase I metabolism)

52
Choosing an opioid in the setting of renal failure

• Minor concern avoid agents with significant
  renal clearance
• Oxycodone
• Fentanyl (Patch/infusion)
• Methadone (gt60 mg/day)
• More important
• Avoid agents with active metabolites that are
  renally cleared
• Morphine
• Codeine
• Meperidine (never appropriate)
• Oxycodone(?) Noroxycodone and oxymorphone
• Andselect agents with inactive metabolites
• Fentanyl (norfentanyl)
• No evidence of increased neuroexcitatory side
  effects
• Hydromorphone (hydromorphone-3 glucuronide?)
• Methadone

53
Summary renal and hepatic failure

• Theoretical reasons to select certain agents
• Although some agents are (theoretically)
  preferable in certain settings, no right or
  wrong choice
• Rules of thumb
• If its not broke, dont fix it (What appears to
  work for a particular patient is a right
  choice)
• Dose escalation should be more conservative in
  renal/hepatic failure
• Virtually any agent can be used effectively by
  starting low and going slow
• When renal/hepatic failure is progressive, be
  prepared to reduce the opioid dose

54
Choosing an opioid when PO intake is limited

• IV/SC route (morphine, hydromorphone, methadone)
• Transdermal (fentanyl)
• Poor choice for rapid titration
• Convincing evidence of ambient heat effect
  (Ashburn, 2002)
• Not optimal when limited sc adipose tissue
• Rectal administration
• Suppositories, liquid, or SR formulation (short
  term)
• Bioavailability is probably 90-100 of oral route
• First pass metabolism depends on site of
  absorption
• Microcapsule formulations of morphine (Kadian,
  Avinza)
• Pudding/applesauce
• PEG tube
• Liquid formulations of methadone (PEG tube)

55
Limited PO intake SC administration of opioids

• For most systems, SC morphine limit is 30 mg/hour
• For higher dose requirements hydromorphone is a
  good alternative (potent, can be concentrated)
• No need for hyaluronidase
• Butterfly needle/change q 5-7 days or with
  discomfort
• D5W preferred diluent

56
Case pain management

• Mr. Palmer received IV morphine in the ER that
  was titrated up to 5 mg/hour at the time of his
  transfer.
• This dose was maintained on transfer
• (His nurse asked Mr. Palmers physician for a
  verbal order for a laxative to prevent
  opioid-induced constipation. He was started on
  senna and colace BID.)

57
Opioid-related side effects

• Side effects
• Sedation
• Nausea/emesis
• Delirium/confusion/agitation
• (Constipation)
• Myoclonus

58
Opioid-induced side effects Overview of options

• Opioid rotation
• Decrease dose
• Add symptomatic therapy
• Change route

59
Opioid-related side effects Sedation

• After 4 hours in the ER, Mr. Palmers pain is
  6/10, and by 8 hours (after transfer) its a 3.
  He is resting comfortably, but is arousable.
• 6 hours later, his nurse notes that Mr. Palmer is
  not arousable, and will not respond to voice.

60
Opioid-induced sedation background

• Prevalence up to 60 of patients, highest in
  initial days of therapy/changes in dose or route
• Differential diagnosis (extensive workup is often
  undesirable)
• Sleep deprivation
• Delayed effects of opioid
• Other
• Internal bleeding/hypotension
• Hepatic encephalopathy
• Pulmonary embolus
• Sepsis

61
The therapeutic window
Somnolence
Pain control
Time ? ? ? ? ? ?
62
The therapeutic window
Somnolence
Pain control
Time ? ? ? ? ? ?
63
Opioid-induced sedation (acute) management

• General strategies
• Assess respiratory status/airway
• Reassure family/staff
• Assess monitoring/nursing capacity
• Specific strategies
• Decrease dose
• Wait
• Avoid naloxone (but bedside availability, 0.4 mg
  with 10 ml water, can offer psychological value)

64
Opioid-induced sedation (subacute) management

• Choice of route? (No good data to support
  independent route effect)
• Opioid rotation. Limited data (Most retrospective
  data)
• Methylphenidate
• Poor database of studies enrolling carefully
  selected patients (Wilwerding et al 1995 Bruera
  1987)
• Evidence of some specific effectiveness but more
  global improvement in well-being

65
Sedation algorithm

• Acute, no respiratory depression?
• If titrating up, change to maintenance dose,
  monitor
• If already at maintenance dose, continue, wait gt6
  hours
• At steady state
• Reduced sleep deficit
• Family/staff reassurance
• Still sedated, consider decreased dose
• Subacute?
• Identify temporal relationships and opioid/pain
  mismatch
• Assess nocturnal sleep, consider hypnotic
• Assess pain control
• Inadequate?opioid rotation
• Adequate?methylphenidate, 2.5 mg BID (AM and
  noon)?10 mg and 5 mg

66
Sedation Outcome

• Mr. Palmers opioids were not increased further
  and he slept for 7 hours without breakthrough
  dosing.
• On awaking, his pain was well-controlled but
  required frequent breakthrough doses. Those
  doses were incorporated into his IV infusion over
  the next 24 hours and the infusion rate was
  increased with no further sedation.

67
Opioid-related side effects Nausea

• As you are titrating morphine gradually against
  pain, Mr. Palmer develops severe nausea with
  repeated vomiting.
• There is no associated abdominal pain,
  constipation, or melena. Bowel sounds are
  somewhat diminished but there is no evidence of
  distention.

68
Opioid-induced nausea background

• Occurs in up to 1/3 of patients
• Usually within first week of therapy
• Typically dose-independent
• Mechanisms of opioid-induced nausea
• Chemoreceptors in CNS
• Impaired GI motility
• Vestibular stimulation
• Conditioning/anticipatory nausea
• Importance of ruling out related causes
• Disease-specific symptoms
• Constipation or bowel obstruction
• Opioid-induced vertigo (lt5)

69
Opioid-induced nausea management

• Limited data, not helpful to extrapolate from
  other common nausea syndromes (e.g. chemotherapy)
• Dose reduction unlikely to be effective
• Interventions
• Switch route (oral?SC) limited data (McDonald
  1991 Drexel 1989)
• Opioid rotation better data (de Stoutz 1995)
• Symptomatic treatment

70
Symptomatic treatment options

• Haloperidol, prochorperazine (Dopamine antagonism
  in CTZ Haloperidol has stronger dopamine
  effects)
• Metoclopramide (Peripheral pro-motility effects,
  anti-dopamine effects at higher doses, e.g. gt10
  mg q 6 hours)
• Scopolamine patch (purely anticholinergic
  effects)
• Also
• Ondansetron (Sussman 1999)
• Lorazepam
• Benadryl
• Dexamethasone (Wang 1999)
• Decreased BBB permeability?
• GABA depletion and inhibition of the CTZ?

71
Nausea algorithm

• Early, aggressive treatment with metoclopramide
• In outpatients prescription for 8 doses with
  opioid prescription
• Inpatients Prophylactic or prn order
• Effective, no emesis?continue and taper
• Ineffective?continue and add haloperidol
• Effective?continue
• Taper haloperidol
• Then taper metoclopramide
• Ineffective?continue
• Rotate opioids
• Consider switch in route

72
Outcome Nausea

• Metoclopramide prn was not effective and was
  increased to a scheduled dose with some relief.
• Simultaneous treatment with metoclopramide (10 mg
  QID) and haloperidol (0.5 mg/6 hours) was
  completely effective. Haloperidol was
  discontinued after 36 hours and metoclopramide
  was discontinued after 3 days with no recurrence
  of nausea.

73
Opioid-related side effects opioid-induced
delirium

• Mr. Palmers pain was well-controlled at a new
  steady dose of morphine, but he becomes agitated
  later that night. He is yelling, trying to pull
  himself out of bed, and seems to be experiencing
  visual hallucinations.

74
Opioid-induced delirium background

• Long differential diagnosis list electrolyte
  abnormalities, physiological causes, terminal
  delirium.
• Mechanisms of true opioid-induced delirium
• Kappa, delta receptors
• Metabolites of parent drug
• Non-specific/pathway effects (e.g. diminished
  arousal, decreased orientation, altered
  sleep-wake cycle)

75
Opioid-induced delirium management

• Very weak evidence base for opioid-induced
  delirium (only extrapolated studies)
• Non-pharmacological interventions are promising
  (also extrapolated)(Inouye 1999)
• Interventions
• Reduce opioid dose(?)
• Opioid rotation best data (de Stoutz 1995)
• Donepezil(?)
• Second generation antipsychotics Strong
  theoretical rationale, anecdotal data, data
  extrapolated from other settings.

76
Delirium algorithm

• Inadequate pain management
• Distressing/agitated delirium? opioid rotation
  symptomatic therapy (low dose haloperidol,
  olanzapine, resperidone)
• Not distressing/ quiet delirium? opioid
  rotation, followed by symptomatic therapy if
  rotation not effective
• Adequate pain management
• Add symptomatic therapy, consider opioid rotation
  if not effective

77
Balancing pain management and side effects

• Confusion is an expected side effect of opioid
  therapy
• However, inadequate treatment of pain can produce
  syndromes of confusion, including delirium
  (Morrison 2003)
• Therefore, confusion/delirium in the setting of
  opioid management
• Should not be considered as an adverse event
• Should not dissuade use of opioids
• Should not prompt discontinuation
• Should be managed carefully

78
Delirium Outcome

• Mr. Palmers agitation responded well to 0.5 mg
  haloperidol PO every 4-6 hours, with higher doses
  at bedtime.
• Additional interventions included
• Move to private room
• Designated CNA (continuity)
• Pictures of family
• Promote normalized sleep-wake cycle through
  interaction during the day

79
Opioid-induced side effects general principles
of management

• Assess pain management
• Inadequate pain management?Opioid rotation
• Adequate pain management? Consider effectiveness
  of available symptomatic therapy
• Reasonable data Add symptomatic therapy
• Weak data consider dose reduction/opioid
  rotation
• NOTE Effective treatment of side effects often
  requires additional medications
• All?Consider a change of route

80
Beyond pain the total care of residents and
families near the end of life

• Mr. Palmers pain and side effects are adequately
  managed on a stable medication regimen. However,
  his interdisciplinary team identifies several
  additional problems, including
• Dry, cracked lips
• Rapid breathing that they are concerned might be
  due to shortness of breath
• Frequent crying spells in one staff member who
  had been very close to Mr. Palmer for the last 5
  years
• The daughters apparently depressed mood and
  expressions of guilt about letting my father die

81
Beyond pain management

• Pain is only one aspect of end of life care
• Residents with pain usually have other physical
  symptoms
• Psychological symptoms are also common
• Grief and bereavement needs are common among
  family, staff, and other residents
• After a residents death
• Before the residents death (anticipatory grief)

82
Pain management in the nursing home the role of
hospice

• Program of care designed to provide comprehensive
  care to patients near the end of life and their
  families
• Eligibility requires patients have a prognosis of
  6 months or less and that they forgo curative
  treatment
• Over 3100 hospice organizations serve almost
  900,000 patients annually
• The Hospice team
• Hospice physicians
• Nurses
• Home health aides
• Social workers
• Clergy or other counselors
• Trained volunteers
• Other disciplines, if needed.
• Medications related to hospice DX
• Bereavement follow up and counseling as needed
  for 1 year

83
A role for hospice in nursing homes

• Strong evidence supporting the value of hospice
  in nursing homes (Miller 2001, Casarett 2001,
  Miller 2002, Miller 2001b, Baer 200, Teno 2004)
• More services
• Better pain management
• Decreased restraint use
• Decreased hospitalization
• Better family satisfaction

84
A role for hospice in nursing homes

• But nursing home residents are underrepresented
  in hospice
• Payment barriers
• Barriers created by institutional culture
• Lengths of stay are very short (median26 days)
• 1/3 enroll in last week
• 10 enroll in last day
• Need for greater hospice access in nursing homes
• Access for more residents
• Access earlier in the course of illness.

85
The role of hospice in the nursing home

• Mr. Palmers family enrolled him in hospice,
  using a community hospice agency that came to the
  nursing home.
• Initial interventions included
• Adjustments to pain medication dosing schedule to
  achieve more even control
• Mouth swabs
• Oxygen and room fan to alleviate sensation of
  dyspnea
• Counseling for both staff and daughter
• Mr. Palmer died 2 weeks later in the nursing
  home, without apparent discomfort.