HOSPICE: OPTIMIZING PALLIATIVE CARE FOR PATIENTS WITH ESRD Judith A. Skretny, M.A. The Center for Hospice

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HOSPICE OPTIMIZING PALLIATIVE CARE FOR
PATIENTS WITH ESRDJudith A. Skretny, M.A.The
Center for Hospice Palliative CareBuffalo, New
York
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• We have been challenged by the RWJF ESRD Workgroup

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• The Challenge
• Collaboration
• Education
• New and Innovative Models of Care

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What is Hospice?

• Is it similar to or different from Palliative
  Care?

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Hospice

• A Philosophy
• A Program
• A Facility
• A Benefit

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Hospice Philosophy

• 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

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Primary Hospice Services

• 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

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The Interdisciplinary Team

• Hospice medical director
• Skilled nursing
• Social work
• Pastoral care
• Home health aides
• Volunteers
• Bereavement programs

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Where Can Hospice Services Can Be Received?

• Home
• Hospital
• Nursing Home
• In-Patient Units

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The Hospice Benefit Includes

• 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

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Eligibility for Hospice Care

• MD certified prognosis lt6 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

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Medicare Hospice Benefit

• 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

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Myths Hospice doesnt admit patients who

• Dont have cancer
• Dont have a DNR
• Are receiving tube feedings or TPN or IVs
• Are receiving chemotherapy or radiation therapy
• Need palliative surgery
• Dont have a primary caregiver

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Unfortunate Reality

• Patients with ESRD who continue to receive
  dialysis cannot access their hospice benefit.

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Hospice

• Interdisiciplinary, compassionate, competent
  end-of-life care that aims to relieve suffering
  and promote QOL for patients and their families

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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.

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Hospice is the pre-eminent practitioner
of palliative care
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HOSPICE PALLIATIVE CAREPALLIATIVE CARE gt
HOSPICE
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Palliative Care

• No specific therapy is excluded from
  consideration. The test of palliative treatment
  lies in the agreementthat 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
  treatments ability to meet the stated goals,
  rather than its effect on the underlying disease.

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Barriers to Hospice Referrals

• 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

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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

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Hospices can assist dialysis units by providing

• 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

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Hospices can assist the medical community by
providing

• Rotation opportunities for nephrologists
• Medical student education
• University affiliated training for social
  workers, PT, OT, nurses, potential nephrology
  specialists

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When the decision has been made to stop dialysis

• Hospices and Dialysis Units can create a seamless
  referral process into Hospice that ensures the
• Same physician will follow the patient
• The process of admission is simple
• Possible scenarios are anticipated and discussed
• i.e. dyspnea, seizures
• The patient and family are supported
  psychologically and spiritually
• Children in the family will receive support from
  child life specialists

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Innovative Programs

• VNA Hospice of Cooley-Dickinson
• Northampton, MA

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Self-Determined Life Closure

• The Death of Ivan Ilyich Tolstoy
• What tormented Ivan Ilyich most was the
  deception, the liethat 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.