My lecture outline
o Describe a brief history of the development of hospice care
o Describe the hospice philosophy of care
o Describe the referral process
o Describe hospice services
o Describe reimbursement in hospice care
o Recognize hospice myths
• Course outline based on Objectives: o Describe a brief history of the development of hospice care, especially ƒ Dame Cicely Saunders, MD and Elizabeth Kubler-Ross, MD • St. Christopher’s Hospice – 1967 – birthplace of modern o Dame Saunders died at St. Christopher’s July 14, • First hospice in United States – 1974 • Received government grant to provide hospice care • Bridge Program – home care with palliative focus and “bridge” to hospice when patient/family is ready • VNA was asked to assist Medicare in writing hospice • Hospice is the only entity for which Medicare pays 100% o Describe the hospice philosophy of care • Emotional, physical, social, and spiritual comfort • The dying person & his/her family as the unit of care • Emphasis on comfort not cure; benefit vs. burden; Quality of Life (“majority of patients are over treated with technology but pain is under treated”) • W.H.O. definition: compassionate care directed at improving quality of life for people with life-limiting illness My lecture outline
not responding to curative treatment; encompasses last 2 – 2.5 years of life (hospice care – usually refers to last 6 months of a person’s life) • “You matter to the last movement of your life, and we will do all we can, not only to help you die peacefully, but to live until you die”. • Physician discusses hospice with pt/family • Pt/family wishes to further pursue hospice options • Writes Order for “hospice consult” • Order sent to social worker per hospital policy • Confirms pt/family wishes to pursue hospice services • Notifies hospice agency chosen by pt/family • Provides additional support to pt/family • Completes evaluation and intake process • Meets with pt/family to discuss hospice services • Life expectancy of less than 6 months • Desire to have treatment focused on comfort rather than • Some may require a caregiver present in the home • Cancer diagnosis with life expectancy of less than 6 My lecture outline
• Atherosclerotic Cardiovascular Disease (ASCVD) • Physical – pain, respiratory distress, fever, nausea and vomiting, hemorrhage, oral-pharyngeal secretions, etc. • Emotional – anxiety, fear, restlessness, agitation, denial, • Spiritual – lack of or faltering spiritual aspect of life, need • Social – unresolved issues, life reviews, “still grandma” • Routine home care, wherever the patient lives o Home
o Nursing home
o Residential home
• Inpatient care, usually in a contracted hospital o Patient is actively dying
o Acute symptom management
o Not covered by Medicaid, considered duplication of
• Respite care, in a contracted nursing home facility o To provide a break or rest for the family and/or o Medicaid covers a total of 5 days for entire time • Continuous care, wherever the patient lives o Crisis care for acute symptom management
o For other crisis within the home
• Medications related to hospice diagnosis and symptom • Specialty and therapy services needed for symptom • Provided by professional team primarily in the home • Personalized, comprehensive services based on patients My lecture outline
o Physician
o Registered nurse
o Medical social worker
o Chaplain
o Home health aide
o Volunteers
o Bereavement coordinator
ƒ Routine inpatient hospice orders (discuss and provide handout) • Admit to VNA Inpatient Hospice per services of John Doe, • Diet: “NPO with mouth care q6h and prn comfort”; or “Comfort Foods as long as no dysphagia and mouth care • Maintain foley per hospital policy – or – May insert and • Reposition q4h and prn comfort (I usually do q4h for dying pts instead of q2h because they seem to remain more comfortable and it causes less agitation and/or • Maintain current O2 protocol; if there isn’t current O2, • No O2 sats or lab draws, nor any other type of diagnostics, procedures, and/or consults. • If they have a peripheral IV, “Do not re-site IV and DC for s/s of infection and/or infiltration” • If they have a PICC, central line, or port, “Maintain – whichever one it is – per hospital policy” • If they have a morphine or dilaudid drip, “Continue morphine drip at (the current rate) and titrate to • Morphine 1 – 4 mg IVP q2h prn pain/sob/respiratory distress and titrate to comfort (Presby cannot give 5mg IVP on the floor, pt must be in ICU for that dosage) • Or – Dilaudid 1 – 2 mg IVP q2h prn . . . . . . . • Ativan 1 – 2 mg IVP q3h prn restlessness/agitation and titrate to comfort (or, substitute haldol if ativan isn’t • Phenergan 12.5 mg IVP or 25 mg supp q4h prn n/v; or, • Tylenol 650 mg supp, 1 PR q4h prn fever • Atropine Opth Gtts 2 gtts SL q2h prn oral-pharyngeal My lecture outline
• Scopolamine Patch 1 TD behind ear and change q72h • If they have a peripheral IV site that we might lose, “Roxanol 20mg/ml, 5 – 20 mg SL q2h prn pain/sob/respiratory distress and titrate to comfort” and “Lorazepam Intensol 2mg/ml, 1 – 2 mg SL q3h prn restlessness/agitation and titrate to comfort” • If they have IVF’s, slow them to a TKO of 10 ml/hr • If they have PEG or NG feedings, for the family’s emotional sake, slow them to ½ of current rate and then DC the following day • May suction prn, but only if Atropine and/or Scopolamine are not controlling oralpharyngeal secretions • Please call VNA Hospice with any change in condition and when pt expires 214-689-2648. TO/Dr.JDoe/RShaw,RN,VNAHospice o Describe reimbursement in hospice care ƒ Per diem
ƒ Medicare
ƒ Medicaid
ƒ Insurance
ƒ Community Funds
• Hospice is for any end-stage disease • Hospice care is a type of care, not a place • Hospice cares for patients where they live • Hospice works best when there is time to build trust and • Recent study shows patients on hospice care live longer


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