HOSPICE:
OPTIMIZING PALLIATIVE CARE
FOR
PATIENTS WITH ESRD
Judith A. Skretny, M.A.
The Center for Hospice & Palliative Car...
We have been challenged by the
RWJF ESRD Workgroup
The Challenge
•Collaboration
•Education
•New and Innovative Models of Care
What is Hospice?
Is it similar to or different from
Palliative Care?
Hospice
• A Philosophy
• A Program
• A Facility
• A Benefit
Hospice Philosophy
• Palliative care for terminally ill patients
and their families
• Control of distressing physical
symp...
Primary Hospice Services
• Physical symptom control-pain, nausea,
dyspnea, etc.
• HHA services-bathing, dressing, feeding
...
The Interdisciplinary Team
• Hospice medical director
• Skilled nursing
• Social work
• Pastoral care
• Home health aides
...
Where Can Hospice ServicesWhere Can Hospice Services
Can Be Received?Can Be Received?
• Home
• Hospital
• Nursing Home
• I...
The Hospice Benefit Includes:
• All drugs related to terminal illness
• All durable medical equipment
• Therapies: OT, PT,...
Eligibility for Hospice Care
• MD certified prognosis <6 mos. If
disease pursues its usual course
• Any terminal diagnosis...
Medicare Hospice Benefit
• Elect Hospice benefit for terminal
illness, sign off Medicare A (hospital)
• PMD may remain pri...
Myths: Hospice doesn’t “admit”
patients who
• Don’t have cancer
• Don’t have a DNR
• Are receiving tube feedings or TPN or...
Unfortunate Reality:
Patients with ESRD who continue
to receive dialysis cannot
access their hospice benefit.
Hospice
Interdisiciplinary, compassionate,
competent end-of-life care that aims to
relieve suffering and promote QOL for
p...
Palliative Care and Hospice
A hospice program provides palliative
care and supportive services to
terminally ill patients,...
Hospice is the
pre-eminent
practitioner of palliative
care
HOSPICE = PALLIATIVE CARE
PALLIATIVE CARE > HOSPICE
Palliative Care
 No specific therapy is excluded from
consideration. The test of palliative treatment
lies in the agreeme...
Barriers to Hospice Referrals:
• Death Denying Society – “giving up”,
“hope”
• Medicine is a death defying profession
• La...
Opportunities for Collaboration
Hospices and Dialysis Units are Natural
Partners in Providing:
• End-of-life education for...
Hospices can assist dialysis units by
providing:
• Training in having “difficult”
conversations
• Support groups for staff...
Hospices can assist the medical
community by providing:
• Rotation opportunities for nephrologists
• Medical student educa...
When the decision has been made to
stop dialysis:
Hospices and Dialysis Units can create a seamless
referral process into ...
Innovative Programs
VNA & Hospice of Cooley-Dickinson
Northampton, MA
Self-Determined Life Closure
The Death of Ivan Ilyich – Tolstoy
 “What tormented Ivan Ilyich most was
the deception, the ...
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THE CENTER FOR EXCELLENCE IN END-OF-LIFE EDUCATION, RESEARCH AND ...

  1. 1. HOSPICE: OPTIMIZING PALLIATIVE CARE FOR PATIENTS WITH ESRD Judith A. Skretny, M.A. The Center for Hospice & Palliative Care Buffalo, New York
  2. 2. We have been challenged by the RWJF ESRD Workgroup
  3. 3. The Challenge •Collaboration •Education •New and Innovative Models of Care
  4. 4. What is Hospice? Is it similar to or different from Palliative Care?
  5. 5. Hospice • A Philosophy • A Program • A Facility • A Benefit
  6. 6. Hospice Philosophy • Palliative care for terminally ill patients and their families • Control of distressing physical symptoms, psychological and spiritual support, and bereavement care • Interdisciplinary team of professionals and volunteers
  7. 7. Primary Hospice Services • Physical symptom control-pain, nausea, dyspnea, etc. • HHA services-bathing, dressing, feeding • Psychosocial counseling-patient and family • Spiritual support-patient and family • Completion of advance directives, wills, funeral planning • Volunteers • Bereavement services
  8. 8. The Interdisciplinary Team • Hospice medical director • Skilled nursing • Social work • Pastoral care • Home health aides • Volunteers • Bereavement programs
  9. 9. Where Can Hospice ServicesWhere Can Hospice Services Can Be Received?Can Be Received? • Home • Hospital • Nursing Home • In-Patient Units
  10. 10. The Hospice Benefit Includes: • All drugs related to terminal illness • All durable medical equipment • Therapies: OT, PT, music, massage, dietary • Other services as approved in plan of care: radiation, chemoRx, TPN, Tx, hydration, surgery • Hospice receives approx. $106/day to provide these services
  11. 11. Eligibility for Hospice Care • MD certified prognosis <6 mos. If disease pursues its usual course • Any terminal diagnosis is appropriate • Treatment goals are palliative rather than “curative” • No therapy excluded pro forma • No DNR required
  12. 12. Medicare Hospice Benefit • Elect Hospice benefit for terminal illness, sign off Medicare A (hospital) • PMD may remain primary, bills Part B • Benefit periods/90/90/60….days • Patient recertified as hospice eligible at beginning of each benefit period … unlimited recertifications • Patient may revoke at any time
  13. 13. Myths: Hospice doesn’t “admit” patients who • Don’t have cancer • Don’t have a DNR • Are receiving tube feedings or TPN or IVs • Are receiving chemotherapy or radiation therapy • Need palliative surgery • Don’t have a primary caregiver
  14. 14. Unfortunate Reality: Patients with ESRD who continue to receive dialysis cannot access their hospice benefit.
  15. 15. Hospice Interdisiciplinary, compassionate, competent end-of-life care that aims to relieve suffering and promote QOL for patients and their families
  16. 16. Palliative Care and Hospice A hospice program provides palliative care and supportive services to terminally ill patients, their families and significant others throughout the course of the illness and into bereavement.
  17. 17. Hospice is the pre-eminent practitioner of palliative care
  18. 18. HOSPICE = PALLIATIVE CARE PALLIATIVE CARE > HOSPICE
  19. 19. Palliative Care  No specific therapy is excluded from consideration. The test of palliative treatment lies in the agreement…that the expected outcome is relief from distressing symptoms, easing of pain, and improvement in quality of life.  The decision to intervene is based on the treatment’s ability to meet the stated goals, rather than its effect on the underlying disease.
  20. 20. Barriers to Hospice Referrals: • Death Denying Society – “giving up”, “hope” • Medicine is a death defying profession • Lack of training/information • Difficulty re: prognostication • Belief that Hospice is for the last days of life
  21. 21. Opportunities for Collaboration Hospices and Dialysis Units are Natural Partners in Providing: • End-of-life education for staff, patients, families • Advance care planning seminars for patients and families • Seminars for staff, patients and families on anticipatory grief, spirituality
  22. 22. Hospices can assist dialysis units by providing: • Training in having “difficult” conversations • Support groups for staff of dialysis units • Information on how to discuss Hospice as part of care planning • Direction on developing bereavement services
  23. 23. Hospices can assist the medical community by providing: • Rotation opportunities for nephrologists • Medical student education • University affiliated training for social workers, PT, OT, nurses, potential nephrology specialists
  24. 24. When the decision has been made to stop dialysis: Hospices and Dialysis Units can create a seamless referral process into Hospice that ensures the: • Same physician will follow the patient • The process of admission is simple • Possible scenarios are anticipated and discussed i.e. dyspnea, seizures • The patient and family are supported psychologically and spiritually • Children in the family will receive support from child life specialists
  25. 25. Innovative Programs VNA & Hospice of Cooley-Dickinson Northampton, MA
  26. 26. Self-Determined Life Closure The Death of Ivan Ilyich – Tolstoy  “What tormented Ivan Ilyich most was the deception, the lie…that he was not dying but was simply ill, and that he only need keep quiet and undergo treatment and then something very good would result.”

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