A patient case study provides the foundation to explore functional status and prognosis in advanced cancer, with hospice as the active plan of care.

1. Advanced Cancer
and End of Life
Module 2
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

2. 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: 06/06/2018 – 06/06/2021.
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 01/31/2021.
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 – RT only receive
CE Credit in Illinois
CE Provider Information

3. 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. 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

4. • 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:

5. • 67-year-old male who presented to his PCP with the following
complaints for past month:
– Cough
– Shortness of breath with exertion
– Mild to moderate left shoulder pain
Clinical Case

6. • Hypertension
• Hyperlipidemia
• Ex-smoker, quit 5 years ago
• COPD, oxygen-dependent
Past Medical History

7. • Married
• One adult daughter
• One 9-month-old grandson
• Works at a T-shirt printing company
Social History

8. • Initial workup by PCP
– Chest X-ray that revealed 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)
Diagnostic Workup

9. • Full staging work 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. • Patient admitted to hospital with:
– Nausea
– Vomiting
– Constipation, no BM x 6 days
– Dehydration
– Anorexia
– Weight loss x 8 pounds
– Increasing left shoulder pain
S/P Chemo-XRT 1-Month Follow-up

11. • Treatment:
– IV fluids
– Ondansetron 6 mg every 6 hours PRN nausea
– Miralax
– Enemas
• Discharged home on Day 4
Hospital Course

12. • 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/day with left shoulder pain 7/10
• Eastern Cooperation Oncology Group (ECOG) performance
status 3, chemo held
• Follow-up appointment in 3 weeks for reassessment
Post-Hospital Oncology Visit

13. • ECOG 2
• Reports feeling better
• Decision to proceed with CXT with 25% dose reduction
Oncology Follow-up 3-Week Visit

14. • Vomiting
• Diarrhea
• Inability to take PO
• Left shoulder pain now 9/10
• New low thoracic back pain x 3 days, unable to move
• Dehydration
• T10 new pathologic fracture
Post-CXT 1-Week ONC Visit

15. • Admitted to acute-care bed
• IV fluids
• Ondansetron IV
• Morphine IV
• High-flow O2
– Interventional radiology able to
perform kyphoplasty
with marked improvement in
thoracic back pain
• Re-imaging reveals:
– Progressive disease –
lymphangitic spread
– Increased lymphadenopathy
– Multiple lytic lesions to bone
(vertebral, ribs, left humerus)
– ECOG 4
Oncology Plan of Care

16. • Due to poor performance status ECOG 4, no cancer-directed
treatment can be provided at this time
• Recommend that he “go home and get stronger,” follow up
outpatient to reassess
• Continue Norco PRN for pain
• Encourage nutritional supplements
• High-flow O2 contributed to an increased length of stay, was a barrier
to timelier discharge
• Discharged home with home health and physical therapy (PT)
Oncology Care Conference

17. • RN visits once per week, assesses vital signs and communicates
with oncology.
• Pain 4/10 on Norco 5/325 mg, 8 tabs/day
• Anorexia
• Ongoing weight loss
• Constipated, using Miralax and Dulcolax suppository PRN
• PT evaluation
– Patient reluctant to participate due to pain in left shoulder,
arm and upper back
– After 3 PT visits, discharged due to failure to progress
Home Health Trajectory

18. • Family contacts oncology office with the following:
– Patient cannot travel to office due to extreme weakness,
debility and pain
– Oncology reports “there is nothing more that can be done”
– Refers to hospice; patient dies within 4 days of hospice
admission
Family Concerns

19. Advanced Cancer.
Is your patient hospice-eligible?
VITAS can help.
Advanced
Illness
Specialists
Expanded
Team
Open
Formulary
Complex
Modalities
High-Acuity
Care
HME and
Supplies
Advance
Care
Planning
Thought
Leadership
Confidential and Proprietary Content

20. • Oncology team recommends that patient/family meet with hospice, because of
poor performance, ECOG 3, intolerance of even dose-reduced chemotherapy
and natural trajectory of advanced lung cancer
– Team to gather information regarding the services hospice can provide and
how hospice can help patient and family
• Family agrees to meet with hospice liaison for information but
wishes to pursue home health, with goals of restorative function
“What-If” Warning Shot: Post-Hospital Oncology Visit

21. 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.
(ECOG 3 and 4 not generally recommended for chemotherapy; burden generally 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

22. Prognostication Tools in Advanced Cancer:
The Role of Functional Status (cont.)
Jang, R. W., Caraiscos, V. B., Swami, N., Banerjee, S., Mak, E., Kaya, E., ... & Zimmermann, C. (2014). Simple Prognostic Model for Patients with Advanced Cancer Based on Performance Status.
Journal of Oncology Practice, 10(5), e335-e341.t
Survival curves for all patients by ECOG performance status and
Palliative Performance Scale (PPS); N= 1,655
Bed or chair > 50% of the time = hospice-eligible

23. • Family notes that despite HH and home PT, patient is not improving
• After a week, they contact their oncologist and request hospice be made
available, given they had met with a hospice liaison earlier and recall all the
services hospice can provide
• Hospice admits patient and the following changes are made to plan of care:
– HME ordered:
• Hospital bed to facilitate transfers and hands-on care
• Over-bed table
• Commode to minimize exertion to bathroom, conserve energy
• Home O2 (concentrator) for use as needed for SOB, with
portable O2 tanks for use when going out
Family Recalls Warning Shot

24. • PT evaluation for home safety and education of transfers
• Hospice physician visit to review the following:
– Goals-of-care 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
QOL and function
• COPD as comorbidity also contributes to function and prognosis
Hospice as an Active POC

25. 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 health care proxy
*Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable.
N=332 *P value<0.05 **P value<0.01 ***P value<0.001
End-of-Life Discussions Align Care
With Patients’ Wishes and Values
Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., ... & Prigerson, H. G. (2008). Associations Between End-of-Life Discussions,
Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.

26. 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<0.05 **P value<0.01 ***P value<0.001
Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., ... & Prigerson, H. G. (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

27. Example of Hospice Care Model for Oncology Patients

28. • 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 patient’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 POC

29. • RN visits patient three times the first week
• Teaches 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 POC

30. • Social worker visits, reviews patient and family concerns, identifies that wife
is struggling
– Counseling is arranged for follow-up
• Chaplain makes contact and is asked to follow up during the second week,
given the patient/family feel overwhelmed by so much first-week activity
– Appointment made for the subsequent week
• Hospice aide services are offered for support with personal care/hygiene
– Given patient is 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 POC

31. • Two weeks after admission, patient feels and functions better, ECOG up to 2,
pain controlled; wishes to speak with oncologist at urging of daughter visiting
from out of state
• Makes appointment with oncologist and has frank discussion about the critical
need to feel better and function better to enjoy to the fullest the time that remains
– Defers on further cancer-directed therapies
• Patient is followed by hospice for 2 months before demonstrating further decline.
During this time, with the help of chaplain and social worker, all funeral
arrangements are finalized
• Patient is able to enjoy time with grandson; hospice volunteers help with memory
making so his grandson will have keepsakes
Hospice as Active POC

32. Temel, J. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., ... & Billings, J. A. (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

33. • Patient does well for additional two weeks at home, slowly declines, becomes
more lethargic, less interactive. During repeat GOC discussion with family, the
ultimate decision is to wean patient’s high-flow O2 to nasal cannula, supporting
greater benefit than burden
• Patient dies peacefully surrounded by family, with hospice nurse in attendance
at his death
• Bereavement services are provided to family for 13 months post death
• Weekly updates are provided to the oncology team throughout the
hospice course; they are notified of patient’s death
Hospice as Active POC

34. 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., Makar, M., Abujaber, S., Dominici, F., Block, S., & Cutler, D. M. (2014). Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for
Patients with Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.

35. Hospice LOS, wks % Pop Non-Hospice Hospice Difference
1 38% $71,582 $66,779 $4,803
2 17% $70,987 $63,013 $7,848
3-4 15% $72,660 $59,595 $13,065
5-8 12% $74,890 $56,986 $17,903
9-26 12% $72,432 $60,326 $12,106
Total Costs Trajectories in Final Year of Life (Non-Hospice vs. Hospice) • For patients on hospice with an
average length of stay of 5-8 weeks,
healthcare costs averaged:
– > $56,986 compared to $74,890
of patients not on hospice
– Cost savings = $17,903
Total Costs Trajectories in Final Year of Life
(Non-Hospice vs. Hospice)
The Benefits of Hospice for Patients Living With Cancer:
The Value Proposition (cont.)
Obermeyer, Z., Makar, M., Abujaber, S., Dominici, F., Block, S., & Cutler, D. M. (2014). Association Between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients with
Poor-Prognosis Cancer. JAMA, 312(18), 1888-1896.

36. Substantial variation exists among providers in how hospice services are delivered
The Value of a Partnership with VITAS
VITAS offers care team members above what the Medicare hospice benefit requires to ensure patients are receiving highest level of symptom management and quality of life,
including respiratory therapist, dietary support, PT/OT/speech, music, expanded pet visits, massage.
Designs and delivers customized, educational plans based on hospitals’ needs and goals, with clinical resources and
technologies to enhance prognostication of advanced illness patients. Experienced clinicians assist with goals-of-care
conversations, specialist consults, medication reconciliation and more.
24/7/365 access to clinicians who triage and treat by phone or can dispatch a clinician to the home/care setting or to conduct a hospice
evaluation. Seamless care transitions any time of day or night. Secure, electronic communication with hospital staff via e-referral
platform partnership, enabling VITAS to receive, manage and respond to hospice referrals in near-real time.
Strong academic and community partnerships focused on research, teaching and patient care. VITAS-sponsored physician fellowships and clinical training
for graduate medical and nursing students, including CME offerings and grand rounds. Technology investments support revolutionary tools for improved
prognostication.
Open Rx formulary for individualized care plans, including continuation of disease-directed medications to assist with pain, respiratory, GI, neurological and constitutional symptoms.
Expanded
Team
Symptom-based anti-tumor therapy, open formulary, multimodal pain management, artificial fluid and nutrition, oxygen, high-flow O2,
BiPAP, CPAP, ventilator removal support, tracheostomy, blood transfusion, TPN, IV fluids, paracentesis, thoracentesis, PleurX drains,
venting G tube, nutritional counseling, proactive wound management.
For patients with acute symptoms, VITAS offers higher levels of care for intensive symptom management and patient stabilization. VITAS supports reduction in
LOS and in-hospital mortality, frees ICU bed availability and reduces likelihood of readmissions associated with alternative post-acute care settings.High-Acuity
Care
Complex
Modalities
Advanced
Illness
Specialists
24/7/365
Clinical
Care
Support
Thought
Leadership
Open
Formulary

37. 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. M., Clarridge, B. R., Casey, V., Welch, L. C., Wetle, T., Shield, R., & Mor, V. (2004). Family Perspectives on End-of-Life Care at the Last Place of Care. JAMA, 291(1), 88-93.

38. Advanced Cancer and
the End of Life
Module 2
Ileana M. Leyva, MD
The information in the pages that follow is considered by VITAS®
Healthcare Corporation to be confidential.

39. References
Jang, R. W., Caraiscos, V. B., Swami, N., Banerjee, S., Mak, E., Kaya, E., ... & Zimmermann, C. (2014).
Simple Prognostic Model for Patients with Advanced Cancer Based on Performance Status. Journal of
Oncology Practice, 10(5), e335-e341.
Obermeyer, Z., Makar, M., Abujaber, S., Dominici, F., Block, S., & Cutler, D. M. (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. S., Greer, J. A., Muzikansky, A., Gallagher, E. R., Admane, S., Jackson, V. A., ... & Billings,
J. A. (2010). Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. New England
Journal of Medicine, 363(8), 733-742.
Teno, J. M. Clarridge, B. R., Casey, V., Welch, L. C., Wetle, T., Shield, R., & Mor, V. (2004). Family
Perspectives on End-of-Life Care at the Last Place of Care. JAMA, 291(1), 88-93.
Wright, A. A., Zhang, B., Ray, A., Mack, J. W., Trice, E., Balboni, T., ... & Prigerson, H. G. (2008).
Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and
Caregiver Bereavement Adjustment. JAMA, 300(14), 1665-1673.