The goal of this webinar was to provide insight and guidance into the challenges of advanced cancer in patients nearing the end of life.

1. Advanced Cancer
and End of Life
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

2. Satisfactory Completion
Learners must complete an evaluation form to receive a certificate of completion. You must participate
in the entire activity as partial credit is not available. If you are seeking continuing education credit for
a specialty not listed below, it is your responsibility to contact your licensing/certification board to
determine course eligibility for your licensing/certification requirement.
Physicians
In support of improving patient care, this activity has been planned and implemented by Amedco
LLC and VITAS®
Healthcare, Marketing Division. Amedco LLC is jointly accredited by the Accreditation
Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education
(ACPE), and the American Nurses Credentialing Center (ANCC) to provide continuing education for the
healthcare team.
Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA
PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent
of their participation in the activity.
CME Provider Information

3. VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through:
VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of
Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.
VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through:
VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE
Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing
Home Administrators and Illinois Respiratory Care Practitioner.
VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB)
Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and
provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing
education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2021 – 06/06/2024.
Social workers completing this course receive 1.0 ethics continuing education credits.
VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board
of Registered Nursing, Provider Number 10517, expiring 01/31/2023.
Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs,
OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RTs only receive
CE Credit in Illinois.
CE Provider Information

4. Goal
• To provide insight and guidance into the
challenges of advanced cancer in patients
nearing the end of life.
• A patient case study provides the foundation
to explore functional status and prognosis in
advanced cancer, with hospice as the active
plan of care. It identifies missed opportunities
that could have supported earlier goals-of-care
conversations, advance care planning, and a
timelier referral to hospice care.

5. • Identify the relationship between functional
status and prognosis in cancer
• Appreciate the benefits to patients of timely
end-of-life discussions
• Recognize the value of earlier hospice
referral for advanced cancer
Objectives

6. • 67-year-old male who presented to his PCP with
the following complaints over the past month:
– Cough
– Shortness of breath with exertion
– Mild to moderate left shoulder pain
Case Study of MK

7. • Hypertension
• Hyperlipidemia
• Ex-smoker, quit 5 years ago
• COPD, oxygen-dependent
• Married, wife is primary caregiver
• One adult daughter
• One 9-month-old grandson
• Works at a T-shirt printing company
Past Medical and Social History

8. • Initial workup by PCP
– Chest X-ray reveals LUL haziness with
changes consistent with COPD
– CT chest confirms LUL mass, irregular
borders, and mediastinal lymphadenopathy
• Interventional pulmonology follow-up with
bronchoscopy with GPS-guided biopsy
• Pathology:
– Non-small-cell adenocarcinoma
(non-small-cell lung cancer, or NSCLC)
– Negative biomarkers
Diagnostic Workup

9. • Full staging PET scan reveals:
– Locally advanced NSCLC
• First-line chemotherapy with
cisplatin and etoposide with
concurrent radiation therapy
– Symptom management
• Norco 5/325 mg, one PO
every 4 hours as needed
for left shoulder pain
Oncology Plan of Care

10. • MK presents with:
– Nausea
– Vomiting
– Constipation,
no BM x 6 days
– Dehydration
– Anorexia
– Weight loss x
8 pounds
– Increasing left
shoulder pain
• Plan: direct admission
to hospital
• MK is admitted to
hospital and medically
managed by
Oncology service
S/P Chemo-XRT First Cycle, 1-Month Follow-Up

11. • Nausea: improves
using ondansetron
• Weakness: spends 12
hours/day in bed or recliner
• Not eating well but takes
PO fluids throughout
the day
• Norco 5/325 mg, takes 8 per
day, with left shoulder pain 7/10
• Eastern Cooperation Oncology
Group (ECOG) performance
status 3, chemotherapy held
• Wife calls and requests PT and
home health at home
Post-Hospital Admission, Oncology Follow-Up After First Cycle

12. • ECOG 2
• Reports feeling better
• MK given second cycle
of chemotherapy and
radiation (CXT)
Oncology Follow-Up 3-Week Visit After Completion
of Home Health and PT

13. • Vomiting
• Diarrhea
• Inability to tolerate PO
• Left shoulder pain
now 9/10
• New low thoracic back
pain x 3 days, unable
to move
• Dehydration
• T10 new pathologic
fracture on imaging
• Admitted to hospital and
medically managed by
oncology service
Post-CXT 1-Week Oncology Visit After Second Cycle
of Chemo-XRT

14. • Due to poor tolerance of CXT,
decision to proceed with 25%
dose-reduced CXT
Post-Hospital Admission Oncology Follow-Up After
Second Cycle of Chemo-XRT

15. • 3 days later, MK presents to ED with
N/V, dehydration, and worsening pain:
– ECOG 3-4
– New pathological T10 fracture,
mets to bone
– Treated with IV fluids and
pain meds
• Discharged home with recommendation
to f/u with oncologist
• Oncologist and PCP discuss curative
vs. palliative treatment options for MK
S/P 25% Dose-Reduced CXT, Third Cycle

16. • Unable to see oncologist
• MK and family have
telehealth visit with PCP and
explore hospice levels of
care and home health as
options after a goals-of-care
(GOC) discussion
One Day Later

17. ECOG
0: Fully active, able to carry on all pre-disease performance
without restriction
1: Restricted in physically strenuous activity but ambulatory and
able to carry out work of a light or sedentary nature
2: Ambulatory. Able to self-care. Unable to carry out work activities
3: Limited self-care. Confined to bed/chair > 50%
4: Disabled. Unable to self-care. Totally confined to bed/chair
5: Dead
(Chemotherapy not generally recommended for ECOG 3 and 4; burden usually greater than benefits)
N = 1,655
Prognostication Tools in Advanced Cancer:
The Role of Functional Status
Functional Status in Advanced Cancer Outcomes
Jang, R., et al. (2014). Simple Prognostic Model for Patients with Advanced Cancer Based on Performance Status. Journal of Oncology Practice, 10(5), e335-e341
Hospice-
Eligible

18. • PT evaluation for home safety and education
on transfers
• Hospice physician visit to review the following:
– GOC discussion addresses advance
directives and healthcare proxy choices
– Given patient’s better understanding,
chooses to have a DNR code entered with
the understanding that he wishes to pursue
any issues that can be treated medically and
provide better quality of life (QOL) and function
– COPD as comorbidity also contributes
to function and prognosis
Hospice as an Active POC

19. End-of-life discussions:
• Give back control to patients
and offer hope
• ARE NOT associated with:
– Physiological distress
compared to those who
do not have end-of-life
discussions
• ARE associated with:
– 2x increased likelihood
of accepting a terminal
diagnosis
– 3x more likely to
complete DNR
– Almost 2x as likely to
complete a power of
attorney compared to
patients who do not have
end-of-life discussions
McGill Psychological Subscale* Total Yes No P value
adjusted least square means (SE) Sample
“Depressed” 7.4 (2.9) 7.3 (0.2) 7.4 (0.2) 0.79
“Nervous or worried” 6.9 (3.2) 6.5 (0.3) 7.0 (0.3) 0.19
“Sad” 7.2 (3.0) 7.3 (0.2) 7.2 (0.2) 0.79
Acceptance, preferences and Total Yes No AOR (95% CI)
planning, N (%) Sample
Accepts illness is terminal 125 (37.7) 65 (52.9) 60 (28.7) 2.19 (1.40-3.43) *
Against death in ICU 118 (35.5) 60 (48.8) 58 (27.8) 2.13 (1.35-3.37) *
Completed DNR order 134 (41.1) 75 (63.0) 59 (28.5) 3.12 (1.98-4.90) *
Completed living will, durable 181 (55.2) 86 (71.7) 95 (46.1) 1.96 (1.25-3.07) **
power of attorney, or healthcare proxy
*Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable.
N = 332 *value < 0.001 **P value = 0.003
End-of-Life Discussions Align Care
With Patients’ Wishes and Values
Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and
Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.

20. End-of-life discussions:
• Changed the care patients
received; care was
associated with a better
quality of life and death
• Reduced:
– ICU admissions by 65%
– Ventilator use by 74%
– Resuscitation by 84%
• Outpatient hospice care
for > 1 week increased 1.6x
compared to those without
end-of-life discussions
Total Yes No AOR (95% CI)a
ICU admissions 31 (9.3) 5 (4.1) 26 (12.4) 0.35 (0.14-0.90)*
Ventilator use 25 (7.5) 2 (1.6) 23 (11.0) 0.26 (0.08-0.83)*
Resuscitation 15 (4.5) 1 (0.8) 14 (6.7) 0.16 (0.03-0.80)*
Out-patient hospice > 1 week 173 (52.3) 80 (65.6) 93 (44.5) 1.65 (1.04-2.63) **
*P value = 0.02 **P value = 0.03
Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and
Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.
End-of-Life Discussions Align Treatments
With Patients’ Wishes and Values

21. Example of Hospice Care Model for Oncology Patients

22. • Medication review:
– Optimization of pain control, long-acting
and immediate-acting opioid
– Addition of gabapentin for nerve-related
pain from brachial plexopathy
– Bowel regimen to avoid further
constipation episodes
– Low-dose Remeron as appetite
stimulant and to aid with sleeping
– Titrated antihypertensive to lower dose,
given MK’s lower BP (not related)
– Continued anti-hyperlipidemia agents
(not related)
– Frank discussion about benefit/burden
of IV fluids. Decision to do time-limited
trial of IV fluids at home and reassess
Hospice as Active Plan of Care

23. • RN visits MK three times weekly
• Educates on medication management,
tracks the number of PRN doses of
immediate-release opioid required
per day. After discussion with hospice
physician, adjusts dose of the
long-acting opioid
• Increased respiratory distress noted
despite titrating oxygen; transitioned
to high-flow O2 by respiratory
therapist (RT)
• Notable improvement in the shooting,
shock-like pain from brachial plexopathy
with addition of gabapentin and titration
pursued slowly
• IV fluids time-limited trial (1 L) is effective;
patient’s nausea resolves, increased
energy and less fatigue are related to
decrease in immediate-release opioids
• Bowel movements regulate, feeling of
fullness resolves, improved PO intake
• SOB improves markedly with transition
to high-flow O2 and oral opioids
• Appetite and sleep improved with
Remeron nightly
Hospice as Active Plan of Care

24. • Social worker visits, reviews concerns
of MK and his family, identifies that
wife is struggling
– Counseling is arranged as follow-up
• Chaplain makes contact and is asked
to follow up during the second week,
as MK and his family feel overwhelmed
by amount of first-week activity
– Anticipatory guidance regarding
grief/grief support
– Appointment made for the
subsequent week
• Hospice aide services are offered
for support with personal care/hygiene
– Given MK is feeling better, family
defers at this time, but is aware
that aide services will be
available and important as
the patient’s condition changes
Hospice as Active Plan of Care

25. Temel, J., et al. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. New England Journal of Medicine, 363(8), 733-742.
Early Palliative Care Impacts Survival

26. • MK does well for additional 2
weeks at home, wife concerned
with ongoing decline and SOB;
ADLs are 6/6 and ECOG of 4
• Care plan interventions include:
– Hospice physician orders
CXR, results consistent
with lymphangitic spread
– Physician readdresses GOC
based on MK’s condition
– Pain and symptom management
continue with long-acting and
immediate-release opioid adjustments
– High-flow O2 initiated
– Social worker and chaplain
revisit with MK’s wife
• 10 days later:
– Despite high-flow O2 and titrated
opioids, MK further declines,
becomes unconscious, and dies
peacefully at home surrounded by
family with VITAS staff in attendance
Hospice as Active Plan of Care

27. NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
The Medicare Hospice Benefit Is a 6-Month Benefit: Quality and
Cost Evidence Corroborate the Need for Timely Access*
*To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being terminally ill. An individual is considered to be
terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or less if the illness runs its normal course. Only care provided by (or under arrangements
made by) a Medicare certified hospice is covered under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the medical director in
consultation with, or with input from, the patient's attending physician, nurse practitioner, physician assistant, and/or physician.
Over the last 12 months of life, as
hospice use increases, total spending
decreases relative to non-hospice
users.
The reduction in costs when patients
across all disease classes, including
neurodegenerative diseases, use
hospice can be significant.

28. NORC at the University of Chicago (2023). Value of Hospice in Medicare. Available at: https://www.nhpco.org/wp-content/uploads/Value_Hospice_in_Medicare.pdf
Comparison of Total Costs of Care by Disease Group and
Hospice Episodes in the 12-Month Period Before Death*
Disease
Group
No
Hospice
Hospice
< 15 Days 15 – 30 31 – 60 61 – 90 91 – 180 181 – 266 > 266
ALL $67,192 4% -5% -9% -12% -14% -10% -12%
Circulatory $66,041 7% -4% -8% -10% -11% -8% -10%
Cancer $76,625 10% -1% -6% -9% -13% -14% -20%
Neuro-
degenerative
$61,004 12% -6% -9% -11% -11% -5% -4%
Respiratory $77,892 -2% -11% -14% -17% -19% -18% -22%
CKD/ESRD $82,781 1% -14% -21% -24% -24% -23% -27%
• Hospice care saved Medicare
approximately $3.5 billion for
patients in their last year of life
• Those patients with hospice
stays of ≥ 6 months* yielded
the highest percentage
of savings
– For patients whose hospice
stays were between 181-266
days, total cost of care
was almost $7K less each
than non-hospice users
– Hospice patients with stays
of > 266 days spent
approximately $8K less each
than non-hospice users
Spending is greater than Spending is less than
non-hospice users non-hospice users
No Difference / Not
Statistically Significant
*To be eligible to elect hospice care under Medicare, an individual must be entitled to Part A of Medicare and be certified as being
terminally ill. An individual is considered to be terminally ill if the medical prognosis is that the individual’s life expectancy is 6 months or
less if the illness runs its normal course. Only care provided by (or under arrangements made by) a Medicare certified hospice is covered
under the Medicare hospice benefit. The hospice admits a patient only on the recommendation of the medical director in consultation
with, or with input from, the patient's attending physician, nurse practitioner, physician assistant, and/or physician.

29. The Benefits of Hospice for Patients Living With Cancer:
The Value Proposition
Utilization Non-Hospice Hospice Odds
Hospital Admission 65.1% 42.3% 1.5
ICU Admission 35.8% 14.8% 2.4
Invasive Procedure 51.0% 26.7% 1.9
Died Hospital/SNF
– Hospital
– SNF
74.1%
50.2%
23.9%
14.0%
3.4%
10.5%
5.3
14.6
2.3
• For Medicare fee-for-service
beneficiaries with poor-prognosis
cancer, those receiving hospice
care vs. not (control) had
significantly lower rates of:
– Hospitalization
– ICU admission
– Invasive procedures
at the end of life
– Total cost
• Patients not on hospice were
14x more likely to die in the
hospital compared to those
on hospice
Obermeyer, Z., et al. (2014). Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients with Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.

30. Substantial variation exists among providers in how hospice services are delivered
The Value of a Partnership With VITAS
Open Formulary for individualized care plans, including continuation of disease-directed medications to assist with pain, respiratory, GI, neurological, and constitutional symptoms.
VITAS nurse supervises medications and compliance to mitigate chances of readmission.
High-Acuity Care for patients requiring intensive symptom management and acute stabilization. Higher levels of care
support reduction in LOS and in-hospital mortality, free ICU bed availability, and reduce likelihood of readmissions.
Advanced Illness Specialists design and deliver customized, educational plans based on hospitals’ needs and goals, and
clinical resources and technologies to enhance prognostication of patients with advanced illness. Experienced clinicians assist
with goals-of-care conversations, medication reconciliation, and more.
Thought Leadership through strong academic and community partnerships focused on research, teaching, and patient care. VITAS sponsors fellowships
and clinical training for medical/nursing students, including CME offerings and grand rounds. Technology investments support improved prognostication.
Expanded Team ensures patients are receiving the highest level of symptom management and quality of life beyond hospice benefit requirements, including: respiratory therapist,
dietary support, PT/OT/speech, music, pet visits, massage, etc.
Complex Modalities for intensive symptom management using anti-tumor therapy, multimodal pain management, artificial fluid and
nutrition, oxygen, BiPAP, CPAP, tracheostomy, blood transfusion, TPN, IV fluids, paracentesis, nutritional counseling, proactive wound
management, etc.
24/7/365 Clinical Care Support provides round-the-clock access to clinicians for triage, assessment, and treatment guidance. Seamless care transitions
available at any time. Secure e-referral platform enables VITAS to receive, manage, and respond quickly to hospice referrals.

31. Outcome Hospice Nursing Home Home Health Hospital
Not enough help with pain, % 18.3 31.8 42.6 19.3
Not enough emotional support, % 34.6 56.2 70 51.7
Not always treated with respect, % 3.8 31.8 15.5 20.4
Not enough information on what
to expect while patient was dying, %
29.2 44.3 31.5 50
Quality care considered excellent, % 70.7 41.6 46.5 46.8
Results are presented only for the 1,380 decedents who had contact with a healthcare institution. Questions regarding quality were not asked of the 198 persons who died at home
without services.
Patient- and Family-Centered Reported Outcomes at the Last Place of Care
(cancer, heart disease, stroke, dementia)
Family members of patients receiving hospice services were more satisfied with overall quality of care:
70.7% rated care as “excellent” compared with less than 50% of those dying in an institutional setting
or with home health services.
The Benefits of Hospice: Patient and Family Experience of Care
Teno, J., et al. (2016). Family Perspectives on End-of-Life Care at the Last Place of Care. JAMA, 291(1), 88-93.

32. Advanced Cancer and
End of Life
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

33. References
Jang, R., et al. (2014). Simple Prognostic Model for Patients with Advanced Cancer Based on
Performance Status. Journal of Oncology Practice, 10(5), e335-e341.
Obermeyer, Z., et al. (2014). Association Between the Medicare Hospice Benefit and Health Care
Utilization and Costs for Patients with Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.
Temel, J., et al. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer.
New England Journal of Medicine, 363(8), 733-742.
Teno, J., et al. (2016). Family Perspectives on End-of-Life Care at the Last Place of Care. JAMA,
291(1), 88-93.
Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health,
Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.

34. This document contains confidential and proprietary business
information and may not be further distributed in any way, including but
not limited to email. This presentation is designed for clinicians and
healthcare professionals. While it cannot replace professional clinical
judgment, it is intended to guide clinicians and healthcare professionals
in establishing hospice eligibility for patients with advanced cancer.
It is provided for general educational and informational purposes only,
without a guarantee of the correctness or completeness of the
material presented.