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The Cycle of Life – Mastering Use of Hospice : 

The Cycle of Life – Mastering Use of Hospice A Presentation of Abundant Life Hospice Department of Continuing Education

Objectives: : 

Objectives: Understand the healthcare provider’s obligation to provide prognostic information Identify appropriate patients for hospice as well as the appropriate time to refer to hospice Understand/Implement plan of care changes to reflect palliative care goals.

Prognosis ~ : 

Prognosis ~ A forecasting of the probable course and outcome of a disease, especially of the chances of recovery. "prognosis." Dictionary.com Unabridged (v 1.1). Random House, Inc. 04 May. 2009. <Dictionary.com http://dictionary.reference.com/browse/prognosis>.

Burdens of Medical Prognostication ~ : 

Burdens of Medical Prognostication ~ Sense of failure, guilt or shame Availability of medical treatments Difficult conversations Potential for error Time requirement is substantial Content in formal education is minimal

Powerful Statements ~ : 

Powerful Statements ~ “There is nothing more we can do.” “It is time to give up.”

Limitations of our expertise ~ : 

Limitations of our expertise ~ “Physicians find prognostication more stressful than other clinical tasks because they believe it reveals their professional limitations.” Death Foretold – Prophecy and Prognosis in Medical Care, Nicholas A. Christakis, MD

Case Study ~ : 

Case Study ~ Inaccurate Prognosis & Avoidance of Prognosis

Benefits of Medical Prognostication ~ : 

Benefits of Medical Prognostication ~ Opportunities for: Advance care planning Cultivate a common vision (MD & patient) Life closure Personal goal achievement Collaboration in medical care planning Aggressive or palliative? Invasive or noninvasive? Where & how to die? And so much more….

Slide 9: 

“A prognosis can radically reshape the physician’s and the patient’s therapeutic management of a condition, resulting, for example, in a shift from a curative to a palliative approach to care.” Death Foretold – Prophecy and Prognosis in Medical Care, Nicholas A. Christakis, MD

What Matters Most ~ : 

What Matters Most ~ Please forgive me. I forgive you. Thank you. I love you. The Four Things That Matter Most, A Book About Living, Ira Byock, MD.

Part 2 – Appropriate Utilization of Hospice : 

Part 2 – Appropriate Utilization of Hospice Finding the appropriate patients at the appropriate time.

How We Die Today ~ : 

How We Die Today ~

Short-Terminal Phase Death : 

Short-Terminal Phase Death

Short-Terminal Death : 

Short-Terminal Death Typically experienced by cancer patients Approximately 25%-30% of deaths This is the trajectory that fits in best with the idea/philosophy of hospice care More predictable decline Patient/family and caregivers hopefully are able to prepare

Slow Decline, Periodic Crisis, Sudden Death : 

Slow Decline, Periodic Crisis, Sudden Death

Slow Decline, Chronic Illness Death : 

Slow Decline, Chronic Illness Death Experienced by CHF, COPD, Renal Failure, Alzheimer’s Dementia, etc…. Approximately 50-60% of deaths Chronic organ failures, repeated cardiac events, recurrent strokes, etc. Very hard to know when the exacerbations will happen or which is the terminal event

Cancer ~ When to Refer : 

Cancer ~ When to Refer The patient declines despite treatment; Chemotherapy is not an option; The patient chooses to forego any aggressive or curative treatment; Has determined comfort care is a priority; Requests order “Do Not Hospitalize” or “Comfort Measures Only.”

Heart Disease ~ When to Refer : 

Heart Disease ~ When to Refer The patient is declining despite optimal therapy for CAD or CHF; 3 or more hospitalizations in one year; The patient is not a candidate for surgical intervention; The patient declines treatment; The patient experiences dyspnea or angina at rest: Class IV Heart Failure

Alzheimer’s & Dementia: When to Refer : 

Alzheimer’s & Dementia: When to Refer The patient speaks 6 or fewer intelligible words per day; The patient is unable to ambulate; Weight loss; Skin breakdown; The patient is incontinent of bladder and bowel; FAST SCALE 7A.

Failure to Thrive ~ When to Refer : 

Failure to Thrive ~ When to Refer Unexplained weight loss Skin breakdown Loss of functional ability 3 or more hospitalizations within the past year for the same symptoms Depressive symptoms (Tearful, crying) Loss of spouse within past 12 months Post surgery without recovery

Keep it Simple ~ : 

Keep it Simple ~ Would the death of this person surprise me if it happened within the next year?

Part 3 - Plan of Care Changes to Reflect Palliative Care Goals : 

Part 3 - Plan of Care Changes to Reflect Palliative Care Goals Aligning Patient Wishes with Appropriate Medical Care

Your patient has chosen hospice care. Now what? : 

Your patient has chosen hospice care. Now what? “When the patient chooses hospice care for treatment of their life-limiting illness, every medical choice must be considered in that light. What was once a standard and appropriate treatment may be invasive and hinder quality of life for this patient. Now is the time to focus on quality of life & comfort in every medical choice.” Teresa Sanderson, RN, CHPN, CEO of Abundant Life Hospice, Inc.

Shifting Gears ~ : 

Shifting Gears ~ Aggressive to Palliative Care “This is the time when we break all of the rules.” Teresa Sanderson, RN, CHPN, CEO of Abundant Life Hospice, Inc.

Questions to ask your patient include: : 

Questions to ask your patient include: What treatments are important to you? Are any treatments really burdensome (physically, financially, or otherwise) for you? Do you understand the benefits and burdens of your medical treatments? What is your idea of an acceptable quality of life? Where do you want to be at the end of your life? Home? Hospital? Do you have goals you want to accomplish before the end of your life?

Let the patient be your guide. : 

Let the patient be your guide. The dying patient and family fears loss of control. Allow as many opportunities for choice, input, and informed decision-making as possible. Adjust the care plan when decisions change.

Let the patient be your guide. : 

Let the patient be your guide. Patients and families have the right to be informed about their condition, treatment options and outcomes. Practice veracity or truth-telling. The patient and family will let us know how much they are able to hear and when they are ready to hear it. Ask, “How much do you want to know?” and “Are your ready for the answer?”

Let the patient be your guide. : 

Let the patient be your guide. The patient and family need to have care provided in a way that is meaningful to them. Provide medical care while at the same time attending to the emotional and spiritual needs of the patient and family. Know important traditions, family structure, cultural background, etc….

Let the patient be your guide. : 

Let the patient be your guide. Patients choosing hospice care have a right to have their wishes honored and respected across the continuum. Advocate for the patient by communicating and collaborating across disciplines and care environments. Be prepared to let the right hand know what the left hand is doing. It is not just our job, it is our obligation.

Medical Considerations ~ : 

Medical Considerations ~ Cancer – no need for additional MRI or CT scan. This testing is mentally burdensome as it only reaffirms what we already know. Diabetes – may discontinue QID blood glucose testing and dietary restrictions; eat dessert first Non-invasive Treatments Only – a pain management plan should never hurt to be administered. No injections, please.

Medical Considerations ~ : 

Medical Considerations ~ Alzheimer’s Dementia – Diet as tolerated, assist with feeding, enteral feedings do not improve outcomes and increase risk of aspiration General – may discontinue vitamins and other non-essential supplements that may be impeding hunger Other palliative interventions?

Summary ~ : 

Summary ~ Mastering utilization of hospice requires attention to the patient experience whether in the ER, physician’s office, or at home. As healthcare professionals, we must recognize when a referral to hospice would benefit the patient and family and provide information to them in a way that is non-threatening. Through open and honest sharing of information, the healthcare provider-patient relationship is transformed into one of intense intimacy and respect.

Questions? : 

Questions?

Thank you for your attention. : 

Thank you for your attention. Abundant Life Hospice has additional programs available on: Hospice: It’s About How you LIVE! Pain Management Basics Life-giving Leadership Creating a Christ-centered Work Environment Mastering the Performance Evaluation Meeting the Psychosocial Needs of the Elderly Additionally, Teresa Sanderson is available as a Keynote Speaker for organizational meetings and events. For more information, call 1-800-983-3881.