why 20hospice 20 handout

							WHY HOSPICE ?


Upinder Singh, MD,FACP
    Patients want to die at home
• 90% of Gallup survey want to die at home
• But deaths in institutions is increasing
  – 1949- 50%
  – 1960- 61%
  – 1980- 74%
• Most deaths could occur at home but lack
  of familiarity with dying process
A dichotomous intent


  Curative / life-prolonging therapy




                                          Death


                Relieve suffering (hospice)
    Why is it so hard to talk about
                dying?
•   Don’t want to think about it
•   My father got mad when I brought it up.
•   We didn’t want to take away his hope.
•   It’s too insensitive.
•   In my culture, it’s an insult.
•   Let’s look at the bright side.
•   Why bother?
        Language with unintended
             consequences

•   Do you want us to do everything possible?
•   Will you agree to discontinue care?
•   It’s time we talk about pulling back
•   I think we should stop aggressive therapy
•   I’m going to make it so he won’t suffer
       Language to describe
        the goals of care . . .

• I want to give the best care possible until
  the day you die
• We will concentrate on improving the
  quality of your child’s life
• We want to help you live meaningfully in
  the time that you have
• Hospice is a special concept of care designed
  to provide comfort and support to patients and
  their families when a life-limiting illness no
  longer responds to cure-oriented treatments.
• Hospice care neither prolongs life nor hastens
  death. Hospice staff and volunteers offer a
  specialized knowledge of medical care, including
  pain management.
• The word "hospice" stems from the Latin word
  "hospitium" meaning guesthouse.
• It was originally used to describe a place of shelter for
  weary and sick travelers returning from religious
  pilgrimages.
• During the 1960's, Dr. Cicely Saunders, a British
  physician began the modern hospice movement by
  establishing St. Christopher's Hospice near London. St.
  Christopher's organized a team approach to professional
  caregiving, and was the first program to use modern pain
  management techniques to compassionately care for the
  dying.
• The first hospice in the United States was established in
  New Haven, Connecticut in 1974.
• Hospice is not a place but a concept of
  care.
• Eighty percent of hospice care is provided
  in the patient's home, family member's
  home and in nursing homes.
• Inpatient hospice facilities are sometimes
  available to assist with caregiving.
   Curative Model          Palliative Model

• Primary goal is cure     • Relief of suffering
• The object of analysis   • The patient and the
  is the disease             family
  process
• Symptoms are treated     • Entities in
  primarily as clues to      themselves
  diagnosis
• Primary value is         • Both measurable and
  placed upon                subjective data are
  measurable data            valued
• Deaths in hospice
  – 11% in 1993
  – 17% in 1995
• Length of stay in hospice
  – 1995: 36 days
  – 1998: 20 days
     Comparing Hospice and Standard
              Home Care
Hospice                           Standard Home Care

Comprehensive, total care         Task-oriented care

Medications related to terminal   Medications not covered
illness covered

Staff on call 24 hours            Scheduled visits

Support for family                Patient care only

Bereavement support               No bereavement support

Physician (some) care covered     Physician care not covered
Prognosis-based eligibility       Home-bound, skilled care need
                        Cancer
Should have 1 OR 2

1. DISTANT METASTASES AT PRESENTATION OR

2. PROGRESSION FROM EARLIER STAGE TO METASTATIC
DISEASE with EITHER a) failure of treatment OR b) refusal of
further treatment

NOTE: Certain cancers with poor prognoses (e.g. small cell lung
cancer, brain cancer, and pancreatic cancer) may be hospice eligible
without fulfilling the other criteria in this section.
                     Coma
Patients with ANY 3 of the following on Day 3 of a coma

a) abnormal brain stem response
b) no verbal response
c) no withdrawal response to pain
d) serum creatinine > 1.5mg/dl

For supportive factors, see 3 under STROKE
      Decline In Clinical Status
(formerly FAILURE TO THRIVE and/or DECLINE IN FUNCTION)
1. PROGRESSION OF DISEASE (no specific number of variables is needed)
A) CLINICAL: 1) recurrent infections such as pneumonia, sepsis, or upper UTI
2) weight loss not from reversible cause such as depression or diuretics 3) falling
serum albumin or cholesterol 4) dysphagia with recurrent aspiration and/or poor
intake
B) SYMPTOMS: 1) dyspnea with increased RR 2) intractable cough 3)
intractable nausea/ vomiting 4) intractable diarrhea 5) increasing pain on
treatment of major analgesic doses
C) SIGNS: 1) systolic BP<90 or postural hypotension 2) ascites 3) venous,
arterial, or lymphatic obstruction 4) edema 5) pleural/ pericardial effusion 6)
weakness 7) change in level of consciousness
D) LABORATORY (not required): 1) Increasing pCO2 or decreasing pO2 or
decreasing SaO2 2) increasing calcium, creatinine or LFT’s 3) increasing tumor
markers (e.g. CEA, PSA) 4) progressive high or low Na or high K+
      Decline In Clinical Status
E) Performance Scale < 70%

F) Increasing visits to ER, MD office, or Hospital

G) Decline in Functional Assessment Staging (FAST) Scale       >7
H) Progressive dependence in ADL’s

I) Progressive decubitus ulcers stage 3 or 4 in spite of treatment

2. NON-DISEASE SPECIFIC GUIDELINES A AND B ARE REQUIRED
A) Performance score < 70% (STROKE and AIDS require a lower score)

   AND

B) Dependence on assistance for 2 or more ADL’s

C) Comorbidities likely to contribute to < 6 months life expectancy: 1) COPD 2) CHF 3)
ischemic heart disease 4) diabetes 5) neuralgic disease 6) renal failure 7) liver disease
8) cancer 9) AIDS 10) dementia
       Dementia of Alzheimers
Patients should have 1 AND 2

1. SHOULD SHOW ALL OF THE FOLLOWING: a) > 7 on the FAST Scale
b) unable to ambulate, dress, and bathe without assistance c) incontinent of
urine and stool d) No consistently meaningful verbal communication:
stereotypical phrases only or the ability to speak is limited to six or fewer
intelligible words       AND

2. SHOULD HAVE HAD ONE OF THE FOLLOWING WITHIN THE PAST
12 MONTHS: a) aspiration pneumonia b) upper UTI c) septicemia d)
multiple stage 3 or 4 decubitus ulcers d) fever, recurrent after antibiotics e)
weight loss >10% in the past 6 months f) serum albumin <2.5gm/dl
                   Heart Disease
Patients should have 1 AND 2; factors from 3 are supportive

1. a) Optimal treatment has already been given (patients who are not on
vasodilators have a medical reason for refusing these drugs, e.g.,
hypotension or renal disease) b) not a candidate for surgery c) refuse
surgery     AND

2. Patients with CHF or angina should meet the criteria for the New
York Heart Association (NYHA) Class IV: a) inability to carry on any
physical activity without discomfort b) symptoms of heart failure or of
the anginal syndrome may be present even at rest c) ejection fraction
of < 20% (is not required, if not already available)
        Heart Disease (cont.)
3. SUPPORTIVE: a) treatment resistant
symptomatic supraventricular or ventricular
arrhythmias b) history of cardiac arrest or CPR
c) history of unexplained syncope d) brain
embolism of cardiac origin e) HIV disease
                   Kidney Disease
Patients should have 1 AND EITHER 2 OR 3; Factors in 4 and 5 are
supportive

1. Not seeking dialysis or renal transplant, or is discontinuing dialysis

AND

2. Creatinine Clearance < 10cc/min (< 15cc/min for diabetics) OR <
15cc/min (< 20cc/min for diabetics) with comorbidity of CHF OR

3. Serum Creatinine > 8mg/dl (> 6mg/dl for diabetics)
          Kidney Disease (cont.)
4. SUPPORTIVE FOR ACUTE RENAL FAILURE: a) mechanical
ventilation b) cancer (other organ system) c) chronic lung disease d)
advanced cardiac disease e) advanced liver disease f) sepsis g)
immunosuppression/AIDS h) serum albumin< 3.5gm/dl I) cachexia j)
platelet count < 25,000 k) disseminated intravascular coagulation (DIC)
I) GI bleeding

5. SUPPORTIVE FOR CHRONIC RENAL FAILURE: a) uremia b)
oliguria (< 400 cc/day) c) K+ > 7 with treatment d) uremic pericarditis
e) hepatorenal syndrome (elevated creatinine and BUN with
oliguria and urine sodium concentration < 10mEq/l) f)
intractable fluid overload, not responsive to treatment
                     Liver Disease
Patients should have 1 AND 2; factors from 3 are supportive

1. PT > 5 seconds over control OR INR > 1.5 AND serum albumin <
2.5gm/dl     AND

2. ONE of the following: a) refractory to treatment or non -compliant ascites
b) spontaneous bacterial peritonitis c) hepatorenal syndrome (elevated
creatinine and BUN with oliguria and urine sodium concentration < 10mEq/l)
d) refractory to treatment or non-compliant hepatic encephalopathy e)
recurrent variceal bleeding, despite intensive treatment

3. SUPPORTIVE: a) progressive malnutrition b) muscle wasting with
reduced strength and endurance c) continued active alcoholism (> 80 gm
ethanol/day) d) hepatocellular carcinoma e) HbsAg positivity f) hepatitis C
refractory to interferon treatment
                   Lung Disease
Patients should have 1 AND 2; factors in 3 are supportive

1. Should have all of the following: a) disabling dyspnea at rest poorly
or unresponsive to bronchodilators, resulting in decreased functional
capacity, e.g., bed to chair existence, fatigue, and cough (forced
expiratory volume in one second (FEV1) < 30% after bronchodilator is
evidence for disabling dyspnea but is not necessary to obtain) b)
increasing visits to the ER or hospitalizations for pulmonary infections
and/or respiratory failure or increasing MD home visits prior to initial
certification (serial decrease of FEV1 > 40 ml/year is evidence for
disease progression but is not necessary to obtain) AND
          Lung Disease (cont.)
2. PO2 < 55 mm/Hg on room air or O2 SAT < 88 on O2 (determined
by either ABG or pulse ox) or pCO2 > 50 mm/Hg (All values can be
obtained from recent hospital records. pCO2 must have been within 3
months.)

3. SUPPORTIVE: a) right heart failure (RHF) secondary to pulmonary
disease (Cor Pulmonale) (e.g., not secondary to left heart disease or
valvulopathy) b) unintentional progressive weight loss > 10% in the
last 6 months c) resting tachycardia > 100/min
                               Stroke
Patients should have 1 AND 2; factors in 3, 4, and 5 are supportive

1. KPS or PPS < 40%        AND

2. Inadequate nutrition with one of the following: a) weight loss > 10% in the
last 6 months or 7.5% in the last 3 months b) serum albumin < 2.5gm/dl c)
history of pulmonary aspiration not responsive to speech language pathology
intervention d) sequential calorie counts documenting inadequate caloric/fluid
intake e) dysphagia severe enough to prevent patient from continuing
fluids/foods necessary to sustain life and patient does not receive artificial
nutrition and hydration

3. SUPPORTIVE: Any of the following in the previous 12 months a)
aspiration pneumonia b) upper UTI (pyelonephritis) c) sepsis d) refractory
stage 3 or 4 decubitus ulcers e) fever recurrent after antibiotics
                    Stroke (cont.)
4. SUPPORTIVE FOR NON-TRAUMATIC HEMORRHAGIC
STROKE: a) large volume hemorrhage on CT: infratentorial > 20ml or
supratentorial > 50ml b) ventricular extension of hemorrhage c)
surface area of involvement of hemorrhage > 30% of cerebrum d)
midline shift > 1.5cm e) obstructive hydrocephalus in patient who
declines, or is not a candidate for, ventriculoperitoneal shunt

5. SUPPORTIVE FOR THROMBOTIC/EMBOLIC STROKE: a) large
anterior infarcts with both cortical and subcortical involvement b) large
bihemispheric infarcts c) basilar artery occlusion d) bilateral vertebral
artery occlusion