Introduction to Hospice and Palliative Medicine

Bansari Patel, APN, ANP

Joan Bigane, APN, FNP

University of Chicago Medical Center

Case Study Mr. H is a 77 y/o AAM with history of Stage 4 Non-

small cell lung cancer. He was initially diagnosed August 2010, after he presented with a persistent cough for 2 months. He has been treated with chemotherapy and radiation. He presents to clinic with worsening SOB and fatigue. The imaging you ordered shows that he has progression of his disease in lung and liver. After reviewing this with him, you ask if he would like to pursue additional chemotherapy.

He responds: “I don’t want any more chemo, can’t you do anything else to make me feel better ?”

Case Study As Mr. H’s health provider, you have seen the

progression of his symptoms/disease and feel that he is appropriate for hospice level care and discuss that with Mr. H.

Mr. H asks “What exactly does hospice care mean?”

Hospice Experience Model Physical Dimension (perceived distress/discomfort)

Functional Dimension (perceived ability to perform ADLs and IADLs)

Interpersonal Dimension (perceived quality of relationships)

Well-being Dimension (perceived sense of “dis-ease”)

Transcendent Dimension (perceived spiritual connection)

Labyak M, Egan K, Brandt K. The experience model: Transforming the end-of-life experience. Hospice and Palliative Care insights 2002;2:9-14

General Principles of Hospice Philosophy of care, not a place Focus on compassionate, holistic end-of-life

care Patient still has autonomy and decision

making Care is directed by the patient and family Dignity/Respect for patient and family

Hospice Q&AMr. H asks you “What services will hospice provide me home?”

Nursing PT/OT/ST

Physician Trained volunteers

Social Worker Respite

Spiritual Support Bereavement Support

Homemaker CAM

Hospice Q & AMr. H asks : “How long has hospice care been around?” “Will I still be able to see my doctor?” “Who pays for it?” “Am I eligible under medicare?”

History of the Hospice Movement Evolving since the 11th century

The hospice movement in the United States has its roots in the work of British physician Dame Cicely Saunders and Dr. Elisabeth Kubler-Ross.

In 1967:,Dr. Saunders founded the first modern hospice -- St. Christopher's Hospice in London, England.

The first hospice in America, the Connecticut Hospice, opened in 1974, followed shortly by an in-patient hospice at Yale Medical Center and a hospice program in Marin County, California

Four years later, the U.S. Department of Health, Education and Welfare published a report citing hospice as a viable concept of care for terminally ill people and their families that provides humane care at a reduced cost.

History of the Hospice Movement Early 1980s, Congress created legislation establishing Medicare coverage

for hospice care. The Medicare Hospice Benefit was made permanent in 1986. Today most states also provide hospice Medicaid coverage.

Today there are more than 3,200 hospices across the country - some are part of hospitals or health systems, others are independent; some are nonprofit agencies, others are for-profit companies

According to the National Hospice and Palliative Care Organization, in 2000 about 1 in 4 Americans who died received hospice care at the end of life - roughly 600,000 people.

How are hospice services covered? Private Pay Some insurances: BlueCross; Aetna; UCHP Medicaid Medicare Hospice Benefit

Case Study Mrs. G is a 46 y/o woman w/ metastatic

breast cancer to her spine. She is currently receiving chemotherapy and has completed radiation to her spine. She presents today with pain to her low back and anxiety. She currently is on long acting opioids and breakthrough opioids. She tells you that it’s not helping. You order imaging of her spine and increase her pain medications.

Case Study The imaging shows stable metastatic disease. You increase her opioids and bring up the

idea of having a palliative medicine team consult.

Palliative Care Q & AMrs. G asks you: “What is Palliative Medicine? Is this

something new?” “What services are provided?” “How much does it cost?” “How often will I get a visit” “Will I still be able to get my chemotherapy?” “Does this mean I’m dying?”

Palliative Care Services Treatment to relieve pain and other symptoms Individual and Family counseling Emotional and spiritual support, including attention

to end-of-life concerns Help in advance care planning Assistance with treatment choices and decisions Home visits (provided by outpatient-based Palliative

Care teams) Help in transitioning to hospice care

History of Palliative Care First US hospital-based palliative care

programs began in the late 1980’s Cleveland Clinic & Medical College of WI. Dramatic increase in hospital-based palliative

care Board certified specialty More than 50 fellowship programs

Reimbursement Medicaid Private Insurance Out of pocket Grants Not Medicare, per se

Benefits of Hospice/Palliative Care Relieves pain and suffering Helps with difficult decision making Palliative care helps patients complete

prescribed therapies Boosts patient and family satisfaction Continuity of care Cost saving

Thought for the day:

When I was 5 years old, my mom always told me that happiness was the key to life.

When I went to school, they asked me what I wanted to be when I grew up.

I wrote down “happy.”They told me I didn’t understand the

assignmentAnd I told them they didn’t understand life.-Anonymous