GR2011-11 But Doctor Isnt It Too Soon for Hospice - Dr. Beaty

BUT DOCTOR, ISN’T IT TOO SOON FOR HOSPICE: 

BUT DOCTOR, ISN’T IT TOO SOON FOR HOSPICE FORREST BEATY, M.D. VITAS HOSPICE CARE

GOALS OF TODAY’S DISCUSSION: 

GOALS OF TODAY’S DISCUSSION 1. To understand the role of hospice in today’s healthcare delivery system. 2. To understand common diagnoses leading to hospice admission and useful criteria for these diagnoses. 3. Identify two useful tools commonly used to evaluate hospice patients for appropriateness.

…WHY WEREN’T WE REFERRED TO HOSPICE SOONER: 

…WHY WEREN’T WE REFERRED TO HOSPICE SOONER By far, the commonest complaint in follow up with families and friends of hospice patients

WHAT IS HOSPICE CARE?: 

WHAT IS HOSPICE CARE? Hospice focuses on caring, not curing. Provides medical care, pain and symptom management and emotional and spiritual support. Provided in home, congregate living facilities, long-term care facilities.

HOW IS HOSPICE CARE DELIVERED?: 

HOW IS HOSPICE CARE DELIVERED? Typically a family member serves as primary care giver. Hospice staff visit regularly to assess patient and provide additional care and support. Hospice is available 24/7

WHAT IS THE HOSPICE TEAM? : 

WHAT IS THE HOSPICE TEAM? Nurses, Volunteers, Physicians, Home Health Aides, Social Workers, Spiritual Counselors, Therapists, Bereavement Counselors.

WHO RECEIVES HOSPICE CARE?: 

WHO RECEIVES HOSPICE CARE? In 2009, an estimated 1.56 million patients received services from hospice. Of 2,450,000 deaths in the U.S., 1,020,000 occurred while under hospice care. 243,000 patients were discharged from hospice in 2009 for reasons including extended prognosis or desire for further aggressive treatment.

HOW LONG DO MOST PATIENTS RECEIVE HOSPICE CARE?: 

HOW LONG DO MOST PATIENTS RECEIVE HOSPICE CARE? The median (50 th percentile) LOS in 2009 was 21.1 days. The average LOS was 69 days

SHORT AND LONG LOS: 

SHORT AND LONG LOS In 2009, approximately 34.4% died or were discharged within seven days of admission. 48.5% died or were discharged within 14 days of admission. 11.8% remained under hospice care for longer than 180 days.

IMPACT OF HOSPICE CARE ON SURVIVAL: 

IMPACT OF HOSPICE CARE ON SURVIVAL 2007 study showed mean survival was 29 days longer for hospice vs. non-hospice patients. Longer lengths of survival were found in four of six disease categories studied. Longest for CHF patients, next for lung, pancreatic and colon cancer. Connor et.al. J Pain Symp Mgmt 2007, Mar: 33(3):238-46

WHERE DO PATIENTS RECEIVE HOSPICE CARE?: 

WHERE DO PATIENTS RECEIVE HOSPICE CARE? Pt’s residence 68.6% Private residence 40.1% Nursing home 18.9% Residential facility 9.6% Hospice in-pt facility 21.2% Acute Care hospital 10.1%

PATIENT GENDER AND AGE: 

PATIENT GENDER AND AGE More than half of hospice patients are female, 53.8% vs. 46.2% 83% are age 65 or older.

ETHNICITY AND RACE: 

ETHNICITY AND RACE White 85% African American 8.7% Asian, PI 1.9% Am. Indian 0.2% Other 8.7%

PRIMARY DIAGNOSES: 

PRIMARY DIAGNOSES Cancer diagnoses 40.1% Non-cancer diagnoses 59.9% Includes Debility Unspecified, Heart Disease. Dementia, Pulmonary Disease, Stroke, ESRD, Motor Neuron Disease, Hepatic Disease, HIV/AIDS, ALS

PAYER SOURCE: 

PAYER SOURCE Medicare 83.4% Private/Managed Care 8.6% Medicaid 4.9% Charity 1.6% Other 1.5%

LEVELS OF CARE: 

LEVELS OF CARE HOME BASED CARE Routine home care: hospice care at place of residence. Continuous Home Care: brief periods of care during crisis or for education of CGs. Care predominantly provided by licensed nursing staff.

LEVEL OF CARE: 

LEVEL OF CARE INPATIENT CARE General Inpatient Care: care in an in-patient facility for symptom management, pain control, etc. which cannot be managed in other settings. Inpatient Respite Care: provided in approved facility on short term basis to provide respite for the CG.

LEVEL OF CARE: 

LEVEL OF CARE Routine home care comprises 95.9% of hospice care.

BEREAVEMENT SUPPORT: 

BEREAVEMENT SUPPORT Hospice is committed to bereavement services for both family members of hospice patients and for the community at large. Bereavement support is offered to grieving families for a minimum of one year following death.

CLINICALLY APPROPRIATE CRITERIA: 

CLINICALLY APPROPRIATE CRITERIA Patient should have a prognosis of six months or less (if condition runs typical course). Patient should agree to a care plan that is palliative in nature, focused on management of the patient’s physical, psychosocial, emotional and spiritual symptoms, rather than on treatment of primary disease.

GENERAL CRITERIA : 

GENERAL CRITERIA The illness is terminal (prognosis 6 mos or less) Declining functional status (Palliative Performance Scale (PPS) 50% or less Dependence in 4 of 6 ADLs Impaired nutritional status (10% loss of body weight in past 4-6 mos.

GENERAL CRITERIA: 

GENERAL CRITERIA Observable and documented deterioration of clinic condition in past 6 mos: Multiple (3 or more) hospitalizations or ED visits Demonstrable decrease in physical activity Decrease in cognitive ability

END STAGE CANCER: 

END STAGE CANCER Category 5: Generally unresponsive to standard therapy Renal cell ca Malignant melanoma Hepatobiliary and gall bladder ca Adrenal ca AIDs associated high-grade lymphoma

END STAGE CANCER : 

END STAGE CANCER Category 4: Treatable in a minority of patients with metastatic disease, less favorable prognosis. Bladder ca Primary brain tumors (Glio, Astro) GYN ca other than ovary Colorectal ca NSCC of lung

END STAGE CANCER: 

END STAGE CANCER Category 3: Treatable, incurable when metastatic, favorable prognosis Prostate ca Breast ca CLL CML, myeloproliferative disorders Low-grade non-Hodgkin’s lymphoma MM and immunoproliferative disorders Thyroid ca (except anaplastic)

END STAGE CANCER: 

END STAGE CANCER Category 2: Treatable, high probability of complete remission, low probability of cure Ovarian ca Adult AML and ALL Intermediate and high-grade non-Hodgkin’s lymphoma Small cell bronchogenic ca

END STAGE CANCER: 

END STAGE CANCER Category 1:Treatable, high or moderate expectation of cure Testicular ca Choriocarcinoma, trophoblastic malignancy Pediatric malignancies Hodgkin’s disease

END STAGE HEART DISEASE: 

END STAGE HEART DISEASE NYHA Class IV CHF Dyspnea and/or other symptoms present at rest or with minimal exertion Inability to carry on physical activity without dyspnea or other symptoms Worsening symptoms if physical activity in undertaken Optimal treatment of CHF, or inability to tolerate optimal treatment.

END STAGE HEART DISEASE: 

END STAGE HEART DISEASE End stage CAD Angina at rest or with minimal activity Symptomatic despite optimal nitrate therapy Not a candidate for, or declines invasive procedures (PCTA, CABG, etc)

COMORBID FACTORS ESCD: 

COMORBID FACTORS ESCD Chronic symptoms of CHF Symptomatic tachydysrhythmias (despite optimum tx) Hx of cardiac arrest Syncope from any cause Cardiogenic thromboembolism Cardio-renal syndrome Age greater than 75 years. Critical aortic stenosis

END STAGE LUNG DISEASE: 

END STAGE LUNG DISEASE Obstructive or restrictive disease Dyspnea at rest or with minimal exertion Symptoms poorly or not at all responsive to bronchodilator therapy Notable progression of disease Frequent use of medical services 2/2 symptoms of pulmonary disease Frequent bouts of bronchitis or pneumonia

END STAGE LUNG DISEASE : 

END STAGE LUNG DISEASE Unintentional weight loss of 10% or more of body weight over prior six months Increasing dependency with regard to ADLs Cor Pulmonale Continuous O2 therapy Resting tachycardia >100/minute Steroid dependent

END STAGE LUNG DISEASE : 

END STAGE LUNG DISEASE Abnormal lab findings FEV1<30% predicted post bronchodilator Serial decreases in FEV1 of at least 40ml/year over several years PO2 <55 tor on room air O2 sat <88% on room air pCO2 > 50 Helpful, but not necessary

END STAGE RENAL DISEASE: 

END STAGE RENAL DISEASE Symptomatic uremia Oliguria (<400cc/24hrs) Hyperkalemia Uremic pericarditis Hepatorenal syndrome Patients refusing dialysis or stopping dialysis

END STAGE RENAL DISEASE: 

END STAGE RENAL DISEASE On dialysis but doing poorly, weight loss, functional loss, cognitive decline. Creatinine clearance <10cc/min (<15cc/min for diabetics)

DEMENTING DISEASES: 

DEMENTING DISEASES Hospice tools include FAST scale (Functional Assessment Scale) 1. No difficulties, subjectively or objectively 2.Forgetting location of objects; difficulty with word finding. 3.Impaired function at work; difficulty traveling to new locations. 4.Decreased ability to perform complex tasks.

FAST SCALE: 

FAST SCALE 5. Difficulty in choosing proper clothing. 6a.Difficulty dressing self. 6b.Difficulty bathing properly. Hygiene aversive. 6c.Inability to handle mechanics of toileting (wiping, flushing). 6d. Urinary incontinence. 6e. Bowel incontinence.

FAST SCALE: 

FAST SCALE 7a. Limited speech; approx. 5-6 words/day 7b. Intelligible vocabulary limited to a single word per day. 7c. Nonambulatory 7d. Unable to sit up without assistance. 7e. Unable to smile or engage. 7f. Unable to hold head up.

PPS (PALLIATIVE PERFORMANCE SCALE): 

PPS (PALLIATIVE PERFORMANCE SCALE) 100%: Normal activity and work. No evidence of disease. 60%: Reduced physical ability, unable to do housework, occas. assistance needed. 50%: mainly sit/lie. Considerable assistance needed. 40%: Mainly in bed, unable to do most activities, need for assistance increased.

PPS: 

PPS 30%: Totally bed bound, total care, intake normal/reduced. 20%: Totally bed bound, total care, minimal sips, occas. bites of food. 10%: Totally bed bound, mouth care only. 0%: death

DEMENTIA: 

DEMENTIA FAST 7a or higher. PPS 30% or lower (variable in vascular dementia). Intercurrent illnesses associated with advanced dementia: Aspiration PNA, UTIs, sepsis, decubitus ulcers (stage 3-4).

DEMENTIA: 

DEMENTIA Impaired nutritional status. Dysphagia or refusal to accept food. If patient tube-fed, weight loss despite tube feedings.

GENERAL DEBILITY & FAILURE TO THRIVE: 

GENERAL DEBILITY & FAILURE TO THRIVE Approx. 10-15% of hospice diagnoses and growing. Multiple risk factors which, when grouped together, meet hospice criteria. Sudden, progressive decline in nutritional status, function, cognition. Diagnostic/treatment may have been offered but declined.

FAILURE TO THRIVE: 

FAILURE TO THRIVE Strictly related to weight loss. BMI <22 Unexplained weight loss Nutritional factors No other medical problems and patient has had functional decline

END STAGE LIVER DISEASE: 

END STAGE LIVER DISEASE Clinical Progression of Disease: Multiple hospitalizations, ED visits or other use of healthcare services. Multiple active co-morbid conditions.

LIVER DISEASE: 

LIVER DISEASE Functional decline: Loss of functional independence Real body weight loss Unable to work Mainly sit/lie Confusion, cognitive impairment

LIVER DISEASE: 

LIVER DISEASE Progressive symptoms refractory to medical management or patient noncompliance: Ascites Hepatic encephalopathy Recurrent variceal bleeding Hepatorenal syndrome

LIVER DISEASE: 

LIVER DISEASE Laboratory indicators: Protime five seconds greater than control or INR>1.5 Serum albumin <2.5gm/dL

LIVER DISEASE: 

LIVER DISEASE Other factors: Progressive malnutrition Continued ethanol consumption Hepatitis seropositivity

HIV DISEASE : 

HIV DISEASE Common conditions identified during last 12 months of life in end stage AIDS in the era of HAART. HIV dementia Progressive multifocal leukoencephalopathy. MAC infection CMV infection Wasting

HIV: 

HIV In late stage HIV, the following characteristics were more predictive of mortality than traditional HIV prognostic variables: Decreased performance status Impaired ADLs Age (>65 yrs)

HIV: 

HIV Opportunistic disease associated with prognosis of 6mos: CNS lymphoma Progressive multifocal leukoencep Cryptosporidiosis MAC bacteremia Visceral Kaposi’s sarcoma

HIV con’t: 

HIV con’t Renal failure Advanced AIDs dementia complex Toxoplasmosis Wasting (loss of 33% lean body mass) Co-morbid condtions (extensive list)

HIV con’t: 

HIV con’t It is important to make sure that HIV infected patients have had an opportunity to be seen by an HIV specialist and have been offered antiretroviral medications.