1. HOSPICE AND END OF LIFE CARE Terence Grewe, DO Family Medicine, Geriatrics and Hospice and Palliative Medicine Tulsa, OK

2. Hospice and Palliative Care Defining Hospice and Palliative medicine The Medicare Hospice benefit Hospice Certification and Recertification Hospice Eligible Diseases Barriers to Hospice and Palliative care

3. Hospice and Palliative Medicine When cure is not possible, treatment goals change: From prolonging life to controlling symptoms New emphasis on advanced planning and ongoing care rather than crisis intervention

4. Hospice and Palliative Medicine Palliative Treatments Enhance comfort Improve quality of life Relieve symptoms and suffering May include medicines, therapies, radiation, surgery

5. The Medicare Hospice Benefit Terminally ill patients with a prognosis of six months or less if the disease follows a normal course Characterized by such evidence as: Documented clinical progression of disease Diminished functional status Recent impaired nutritional status

6. Medicare Certification At admission two physicians must certify that the patient has a terminal illness with a prognosis of 6 months or less if the disease runs a normal course. Attending Physician Hospice Medical Director

7. Medicare Certification Patients may receive hospice care as long as the Hospice Medical Director continues to certify that the patient has a terminal illness with a prognosis of 6 months or less if the disease runs a normal course. Certification intervals: An initial 90-day period; A second 90-day period; Followed by an unlimited number of 60-day periods.

8. Medicare Certification Based on Medicare’s own indicators of terminal prognosis. Includes narrative summaries by the hospice medical director or attending physician. Requires face-to-face encounters by the hospice physician or hospice nurse practitioner for patients who are beginning any 60 day election period.

9. Hospice Eligible Illnesses Terminal Cancer/ Malignancy End-Stage Cerebral Vascular Disease End-Stage Pulmonary Disease End-Stage Dementia (Alzheimer's) End-Stage Cardiac Disease End-Stage Renal Disease

10. Hospice Eligible Illnesses End-Stage AIDS End-Stage Neurological Disease (ALS, Parkinson’s, MS) End-Stage Liver Disease Adult Failure to Thrive and Debility are no longer Hospice diagnosises

11. Functional Assessment and Eligibility Karnofsky Scale Modified Activities of Daily Living Descriptive Scale

12. Karnofsky Scale 10Normal, no complaints or evidence of disease 9Able to carry on normal activity, minor signs and symptoms of disease 8Normal activity with effort, some signs and symptoms of disease 7 Cares for self, but unable to carry on normal activity or do normal work

13. Karnofsky Scale 6Requires occasional assistance, but can care for most of own needs 5Requires considerable assistance and frequent medical care 4Disabled, requires special care and assistance

14. Karnofsky Scale 3Severely disabled, hospitalization would be indicated, death is not imminent 2Hospitalization would be necessary, very sick, active supportive treatment is necessary 1Moribund, fatal processes progressing rapidly 0Death

15. Modified ADL Bathing 4 Independent 3 Uses a device 2 Needs personal assistance 1 Completely dependent

16. Modified ADL Dressing 4 Independent 3 Uses a device 2 Needs personal assistance 1 Completely dependent

17. Modified ADL Toileting 4 Independent 3 Uses a device (walker, cane) 2 Needs personal assistance 1 Completely dependent

18. Modified ADL Transfer 4 Independent 3 Uses a device (walker, cane) 2 Needs personal assistance 1 Completely dependent

19. Modified ADL Continence 4 Independent 3 Uses a device independently 2 Needs personal assistance 1 Completely dependent (catheter, diaper)

20. Modified ADL Feeding 4 Independent 3 Uses a device 2 Needs personal assistance 1 Completely dependent (feeding tube or not eating)

21. Descriptive Scale Anorexia 1 No fluids 2 Some fluids 3 Some soft foods 4 Decreased intake 5 Normal

22. Descriptive Scale Cachexia 1 Skin and bones 2 Extreme cachexia 3 Very thin 4 Normal build 5 Heavy

23. Descriptive Scale Mobility 1 Unable to turn over 2 Sits up 3 Bears weight 4 Limited walking 5 Normal

24. Descriptive Scale Pain 1 Incapacitated 2 Severe 3 Moderate 4 Mild 5 None

25. Descriptive Scale Dyspnea 1 Incapacitated 2 Severe 3 Moderate 4 Mild 5 None

26. Hospice Eligible Illness: Alzheimer’s Alzheimer’s Disease Bedfast or chair bound Minimally communicative Infections and complications Co-morbidities Evidence of decline

27. Alzheimer’s Criteria and Progression The patient is chair bound The patient doesn’t effectively communicate The patient has lost weight The patient has had infections

28. Alzheimer’s: Additional information Arm circumference? Any lab available? Any other conditions such as CHF, COPD, CAD? Change in ADLs, feeding, etc?

29. Alzheimer’s Disease: An Example Patient has advanced Alzheimer’s, is bedfast, requires assistance for all ADLs, has had 2 UTIs and has lost 5 pounds in the last 3 months. The patient is eligible to receive hospice care.

30. Alzheimer’s Disease: A Second Example A 92 y/o male with moderate Alzheimer’s, moderate CHF, a BMI of 21 with recent 10 pound weight loss has become more dependent on ADLs, now needs assist with meals and has been spending more time in bed. He does ambulate short distances with a walker and can carry on a short conversation.

31. An Example 92 year old male with Alzheimer’s, CHF, weight loss decline in functioning and dependence in all ADLs is showing signs of terminal decline and is eligible to receive hospice care.

32. Hospice Eligible Illness: Cancer Diagnosis confirmed by pathology or radiology No curative treatment (palliative is ok) Evidence of end stage disease or metastasis Studies show progression Karnofsky <=5, ADL<=18 Descriptive<=25

33. Hospice Eligible Illness: End Stage Cerebral Vascular Disease Marked decreased appetite/ intake Chair bound or bed bound Karnofsky <=4 ADL <=8 Descriptive <=18

34. Hospice Eligible Illness End Stage Renal Disease BUN >75mg/dl, Creatinine >5 U/L No dialysis Chronic or acute illness precipitated renal failure Karnofsky <=6 ADL <=20 Descriptive <=22

35. Hospice Eligible Illness End Stage Pulmonary Disease No ventilatory support Multiple pulmonary medications O2 dependent Minimal activity results in severe dyspnea Karnofsky <=5, ADL <=18 Descriptive <=20

36. Hospice Eligible Illness End Stage Cardiac Disease Dyspnea with minimal exertion Azotemia evidenced by elevated BUN Multiple cardiac medications Abnormal EKG or ejection fraction 20% CHF/ Cardiomyopathy: evidence of fluid overload in spite of medications

37. Hospice Eligible Illness End Stage Cardiac Disease CHF/ ASHD/ ASCVD/ Ischemic heart disease: evidence of angina, arrhythmias, previous MI’s Karnofsky <=6 ADL <=20 Descriptive <=20

38. Hospice Eligible Illness End Stage AIDS Not receiving TPN Not receiving AZT or IV treatments CD4 <50mm3 Successive opportunistic infections Karnofsky <= 5 ADL <=12 Descriptive <=16

39. Hospice Eligible Illness End Stage Neurological Disease Parkinson’s, ALS, MS Bed bound, chair bound No ventilatory support Karnofsky <=5 ADL <=8 Descriptive <=21

40. Hospice Eligible Illness End Stage Liver Disease Documentation of specific liver disease Abnormal liver enzymes Jaundice, ascites, edema Abnormal coagulation (PT) Karnofsky <=6 ADL <=20 Descriptive <=19

41. Role Of Hospice Programs Provide comprehensive palliative care to terminally ill patients and their families Views dying as a natural part of life Seeks neither to hasten nor postpone death Emphasizes living each day to its fullest

42. Hospice Team Members Attending Physician Hospice Medical Director Patient Care Coordinator (RN) Nurses (RN, LPN) Home Health Aids Social Workers Chaplains

43. Barriers to Hospice and Palliative Care Late referrals: due to attitudes about death by physicians, patients and families Prognosis-related issues: accurately predicting prognosis is often difficult

44. End of Life Issues Recognize life-ending disease processes and address them with patients and families Help patients make end-of-life decisions such as living wills, power of attorney and DNR Consider Hospice and Palliative care when cure is not an option

45. End of Life Issues Physicians can help patients and their families face the end of life, make reasonable end of life decisions and eliminate suffering to allow the patient to live their last days to the fullest.

46. HOSPICE AND END OF LIFE CARE Terence Grewe, DO Associate Medical Director RoseRock Healthcare