1. The Role of the Respiratory Therapist in Hospice/Palliative Care Tim Buckley, RRT, FAARC Director Respiratory Services Walgreens Home Care

2. Role of the RT in Palliative Care Why is this something that we should talk about? How does a Medicare Hospice work? Is there a role for respiratory therapists in the care of Hospice patients? What are some potential advantages of using RTs in the care of Hospice patients?

3. Why should we talk about RTs in Hospice Care? Of the top ten causes of death, 3 are “RT diagnoses” –COPD –Pneumonia –Lung Cancer RTs are expert in the assessment and treatment of dyspnea in all care settings RTs are expert in the management of secretions in all care settings

4. Hospice Care Active total care of patients whose disease is not responsive to curative treatment Control of pain, of other symptoms Psychological, social and spiritual support is paramount The goal of hospice care is the best quality of life for patients and their families Principles in Palliative Care: An Overview Joseph Fins, Respiratory Care, November 2000

5. Medicare Hospice Model Patients with a terminal diagnosis and a prognosis of 6 months or less are eligible CMS pays the Hospice a per diem for each patient enrolled for the time they are enrolled Hospice is responsible for all of the care related to the hospice “diagnosis” If the patient survives 6 months, they can be re-certified for hospice care

6. Hospice Economics Hospice census is critical to success All services are “cost reported” to set per diem rates All charges for “allowed” expenses are cost reported The best “financial” situation is long term patients who uses minimal services

7. Hospice Structure Medical Director admits all of the patients Nurses “case manage” each patient be developing a care plan that serves as the prescription Typically nurses, CNAs, housekeepers, transportation, social work, pain management, counseling, and spiritual care are provided. Equipment is also provided and can be cost reported What’s Missing?

8. Medicare Recognizes Respiratory Care as a Hospice Benefit In 2005, in response to a question from the AARC, CMS stated that Respiratory Care is a covered hospice benefit This allows respiratory care services to be cost reported and included in the per diem payment for hospice services.

9. What are the possible roles for an RT in Hospice care? Assessment and treatment of dyspnea Management of secretions Airway management Aerosol therapy Non-invasive ventilation Invasive ventilation Staff educator Case manager

10. Assessment of Dyspnea In the last weeks of life 90% of COPD patients, 90% of lung cancer patients, & up to 70% of Hospice patients experience dyspnea Dyspnea does not always correlate well with traditional diagnostic evaluation Dyspnea manifests itself differently in different patients Nothing effects quality of life more Dyspnea Assessment, Sorenson, Respiratory Care November 2000

11. Treatment of Dyspnea Drug therapy –Opiates –Anti anxiety –Anti depressants Oxygen Air Alternative medicine techniques Dyspnea Treatment, Manning, Respiratory Care, November 2000

12. Managing Secretions Assessment is key to how to treat –Is it saliva or sputum? Positioning,nutrition & hydration all play roles Therapeutic interventions Suctioning Drug therapy Managing Secretions in Dying Patients, Sorenson, Respiratory Care, November 2000

13. Other areas of expertise Pulmonary Rehabilitation –Exercise & techniques Non invasive ventilation –Especially in chronic respiratory failure Invasive Ventilation –Withdrawing support Airway management

14. Advantages of using RTs in Hospice Care RTs are experts in the diseases RTs are experts in the treatment of dyspnea RTs are great educators of the patient & family as well as staff members RTs are more “cost effective” than RNs Having an RT may help to “recruit” patients earlier in the course of the disease RTs can move the focus from the equipment to the patient.

15. What do we need to do? Educate RTs about palliative care –It effects us all in every practice setting –RT need to know more about pharmacy of palliative care Educate Hospices about RTs –What do we do well? –How we can be more cost effective Develop evidence based techniques for dyspnea assessment and management

16. Questions?