Webinar presented by VITAS Healthcare on December 14, 2017. Presented by Hari Nagaraj, MD, FACP

1. Exploring Hospice Care
The Who, What, Where, Why and
How of End-of-Life Care

2. Care at the End of Life
Statistics show that while most
people hope to die at home,
approximately 50% of the general
population dies in an acute care
hospital setting. The chances,
however, improve with hospice—
which allows three out of four
hospice patients to die in
their home
Journal of Oncology Practice, 2008

3. How We Die…
Misleading Information
<10% suddenly, unexpected event, MI, accident, etc.
>90% protracted life-threatening illness
• Predictable steady decline with a relatively short
“terminal” phase (e.g cancer)
• Slow decline punctuated by periodic crises (e.g CHF,
emphysema, Alzheimer’s)

4. Goal
To educate healthcare professionals
about the benefits of hospice, in order to
provide timely, quality end-of-life care for
terminally ill patients and their families

5. Objectives
• List two myths about hospice care
• Identify the difference between palliative and
curative care
• Explain services provided under the hospice benefit
• List four eligibility criteria for hospice services
• Describe how hospice is structured to meet the
needs of terminally ill patients and their families

6. Your Thoughts?
Many people already know something
about hospice…
What are your perceptions
and/or experiences?

7. Hospice Origins
• The origin of the word hospice was used
to describe a “shelter or haven for the
weary traveler”
• The term “hospice” has come to be
associated with support and care
• Shelter from discomfort is provided to
enable dying patients to approach death
in a peaceful way

8. History of Hospice
• 1905 St. Joseph’s, London
• 1967 St. Christopher’s, London
• 1969 Elisabeth Kubler-Ross (On Death and Dying)
• 1974 New Haven Hospice of CT
• 1978 National Hospice Organization — now called
the National Hospice & Palliative Care Organization
(NHPCO)
• 1979 First state hospice licensure law
• 1982 Congress enacts Medicare hospice benefit

9. Hospice Facts
Question #1
What are some of the most
common misconceptions you’ve
heard from providers and families
about hospice?

10. Hospice Misconceptions
• Hospice is a place
• Someone dies right away
• Hospice is for those who are in their last
days of life
• Hospice/palliative care means “doing nothing”
• All treatments are discontinued

11. What is Hospice?
• Affirms life
• Regards dying as a normal process
• Focus is on the patient’s physical, spiritual,
emotional and social needs
• Neither hastens nor postpones death
• Expert medical care, pain management and
emotional/spiritual support
• The belief that each person has the right to
die pain-free and with dignity

12. Hospice Interdisciplinary Team
Photo retrieved May 2, 2013
from:http://www.hospicebr.org/s3web/1001964/Images/1001964interdisciplinaryt
eamdiagram.jpg
The plan of care is
determined by the
patient & caregiver
Hospice care is
focused on their needs
and quality of life

13. Palliative Care
• Palliative care means patient- and family-centered care
that optimizes quality of life by anticipating, preventing
and treating suffering
• Palliative care should be given throughout the
continuum of illness and involve management of
physical, intellectual, emotional, social and spiritual
needs and facilitate patient autonomy, access to
information and choice
73 FR 32204, June 5, 2008
Medicare Hospice Conditions of Participation – Final RuleV
Copyright 2008 Center to Advance Palliative Care.
Reproduction by permission only.

14. Hospice. A Type of
Palliative Care
• The aggressive treatment of physical, social and emotional
pain & symptoms at the end of life
• An active treatment plan, not intended to cure the disease
• Palliative treatment focuses on enhancing a patient’s
comfort and overall quality of life
• Palliative care redirects energy
– Patient and family drive the plan of care and decide
what is important to accomplish
– Focus can be on physical, psychosocial or spiritual –
or all three

15. Palliative Care Improves
Quality and Reduces Costs
• Hospice programs demonstrate high patient
satisfaction and quality of care for terminally
ill patients
• A 2012 study found that 96% of physicians
supported palliative care

16. Palliative Care Improves
Quality and Reduces
Costs (Cont.)
However
• 42% of MDs expressed concern that emphasizing
palliative care could interfere with treatment
aimed at extending lives
• 25% of MDs were reluctant to recommend
because patients may perceive they are not doing
everything possible to extend their lives

17. Curative vs. Palliative Care
Curative Treatment
• Disease driven
• Doctor in charge
• Disease process is
primary focus
• Few choices
Palliative Care
• Symptom driven
• Patient is in charge
• Disease process is
secondary to person
• Many choices
• Comfort & quality of life

18. What Do Patients With
Serious Illness Want?
• Pain and symptom control
• Avoid inappropriate prolongation
of the dying process
• Achieve a sense of control
• Relieve burdens on family
• Strengthen relationships with
loved ones
Hospice Management Advisor, 2011

19. Hospice Facts
Question #2
What percentage of Medicare patients
started a new course of chemotherapy
within two weeks of their death?

20. How Long Should Aggressive
Treatment Continue?
• More than 20% of Medicare patients who have
advanced cancer start a new chemotherapy
regimen two weeks before they die
• Only 37% of MDs told patients how long they
had to live, even when patients asked for the
information
• Patients frequently learn more about their
prognosis from other patients in the waiting
room than from their doctors, authors say
Journal of the American Medical Association (2008).

21. Hospice Facts
Question #3
What percentage of hospice admissions
were of a minority race?

22. Hospice Facts – 2012
(NHPCO)
Answer:
Only 17.2% of hospice
admissions were of a
minority race
National Hospice and Palliative Care Organization, 2012

23. Example
African-Americans’ underutilization
of hospice services
• Stronger preference for aggressive care
• Lack of knowledge about hospice
• Religious/hope factors
• Mistrust of healthcare system
National Hospice and Palliative Care Organization, 2012

24. Hospice use among minorities
• Only one in five patients are of a minority race
• Cancer diagnoses account for less than half of
all hospice admissions (37.7%)
• 1/3 of all deaths in the US were under the
care of a hospice program (1.65 million
patients)
• 44.6% of all deaths in the US were under the
care of a hospice program
“The greatest challenge is having honest
conversations with patients and their families
so we can bring the appropriate resources
to bear.”
National Hospice and Palliative Care Organization, 2012

25. Hospice Facts
Question #4
What is the average length of service
for hospice patients?

26. Answer
• The average length of service is 69.1 days
• However, the median length of service in 2011
was only 19.1 days
– This means that half of hospice patients
received care for less than three weeks and half
received care for more than three weeks
National Hospice and Palliative Care Organization, 2012

27. Hospice Facts
Question #5
What percentage of patients died or were
discharged in seven days or less of service?

28. Answer
35.8% of hospice patients were
discharged in seven days or less
National Hospice and Palliative Care Organization, 2012

29. Hospice Facts
Question #6
How many patients died or were discharged
180 days or more after admission to
hospice?

30. Answer:
11.4% of patients died or were discharged
180 days or more after hospice admission
National Hospice and Palliative Care Organization, 2012

31. Short and Long Lengths of
Hospice Services
National Hospice and Palliative Care Organization, 2012
Experts agree that
hospice patients gain
the full benefit of
hospice when
provided for at least
three months

32. Hospice Reduces Medicare
Healthcare Costs
• Hospice services save money for Medicare and
bring quality care to patients with life-limiting illness
and their families
• Duke University : Hospice reduced Medicare costs
by an average of $2,309 per hospice patient
• Reduced costs for seven out of 10 hospice
recipients if hospice has been used for a longer
period of time
Taylor DH Jr, Ostermann J, Van Houtven CH, Tulsky JA, Steinhauser K. What length
of hospice use maximizes reduction in medical expenditures near death in the US
Medicare program? Soc Sci Med. 2007 Oct;65(7):1466-78.

33. Patients on Hospice
Live Longer
Recent study of 4,493 patients with
CHF or cancer of breast, colon, lung,
prostate or pancreas
• Mean survival was 29 days
longer with hospice care than
those who did not choose hospice
Connor ST, Pyenson B, Fitch K, Spence C, Iwasaki K.
Comparing hospice and non-hospice patient survival among patients who die
within a three-year window. Journal of Pain and Symptom Management.
2007 Mar; 33(3):238–46

34. Question Break

35. Medicare Hospice Benefit
• Part A Medicare Benefit
• Terminal illness
• Certified by two physicians
• Comfort, not cure
• Covers 100% of costs related to the
terminal diagnosis
• Unlimited election periods if criteria met
for recertification

36. Hospice Certification
and Recertification
Divided into distinct periods
• Two benefit periods of 90 days each
• Followed by unlimited number 60 day
benefit periods
• Prior to the start of any new benefit period
the hospice team is required to recertify the
patient’s terminal prognosis

37. Medicare Hospice Benefit:
Service Components
• Medical direction and physician participation in the
development of the plan of care
• Expert pain and symptom management 24/7
• Medications, DME, medical supplies related to
terminal diagnosis
• Dietary counseling, speech, physical and
occupational therapy as indicated
• Education/support of family/caregivers
• Bereavement services for up to 13 months

38. Presenting the
Hospice Benefit
• What challenges do you face when you
present hospice as an option?
• Have there been difficult responses with the
member or their family?
• Has the physician explained the terminal
illness before you talk to the member?

39. Hospice Interdisciplinary
Team
• Attending physician
• Hospice physician
• Nurse (RN & LPN)
• Social worker
• Chaplain/clergy
• Hospice aide
• Trained volunteer

40. Eligibility Criteria: General
• Patient preferences
–Patient’s personal goals
–Burden of treatment vs. potential benefit
• Changes in functional status
–Dependence in at least 3/6 activities of daily
living (non-cancer patients)
• Unintentional weight loss
–> 10% of normal body weight
–Body Mass Index (BMI) < 22 kg/m2
Kinzbrunner, Barry
20 Common Problems in End-of-Life Care (Ch 1)
New York, McGraw Hill, 2011

41. General Criteria: Clinical
Progression of Disease
• Increased utilization of health care resources
–Multiple hospitalizations
–ED visits
–Other health care services
• Disease progression
–Serial physician assessments
–Laboratory or diagnostic studies
• Changes in MDS in LTC facilities
• Decline identified by home health care provider
Kinzbrunner, Barry
20 Common Problems in End-of-Life Care (Ch 1)
New York, McGraw Hill, 2011

42. End-of-Life Symptoms
• Unrelieved pain
• Frequent infections
• Repeat hospitalizations
• Weight loss/swallowing difficulty
• Inability to ambulate independently
• Nausea or vomiting
• Withdrawn, confused, bed-bound
• Shortness of breath/oxygen dependent
• Progressive decline despite use of curative
medical therapies

43. Terminal Diagnosis:
Examples
• Cancer
• End stage non-cancer diseases:
– Alzheimer’s disease/dementia
– Heart disease
– Lung/respiratory disease
– Kidney disease
– Liver disease
– Stroke
– AIDS-related diseases

44. When is it Time to
Consider Hospice?
Would I be surprised if
this patient died in the
next six months?

45. Medicare Hospice Benefit
Four Levels of Care
• Routine Home Care
• Continuous Care
• Inpatient Care
• Respite Care

46. Hospice:
Routine Home Care
• Most frequently delivered level
of care
• Proactive plan of care
• Frequency of visits by the
care team is determined by
the needs of the patient

47. Hospice: Continuous Care
Goal: To avoid a hospitalization
• Indicated during a period of crisis
• Patient desires to stay at home, but requires more
intensive medical care
• Minimum of eight hours of care per day; > 50%
must be provided by a nurse
• Reimbursement is hourly — based on the number
of actual hours of care
• Examples: Uncontrolled pain, dyspnea, bleeding,
change in level of consciousness, nausea/vomiting

48. Hospice:
General Inpatient Care
Goal: acute symptom management when issues
cannot be controlled in the home setting
• Pain, nausea/vomiting, agitation, seizure,
dyspnea, bleeding, wound care, etc
• Care may be provided in:
– Free-standing units
– Leased wing of hospital/LTC facility
– Contract beds

49. Hospice: Respite Care
Goal: Short-term inpatient care provided to
relieve the patient’s caregiver
• Must be provided by a hospice, hospital, skilled
nursing facility or intermediate care facility staffed
with a 24-hour RN
• Respite care may be provided only on an
occasional basis and may not be reimbursed for
more than five consecutive days at a time

50. The Value of Hospice
Think about which hospice benefit is most
important to your members?
• Care delivered in their home
• Management of pain and symptoms
• Coverage of medications and medical needs
related to the terminal condition
• Additional caregiver support
• Spiritual care

51. Hospice Facts
Question #7
True or False?
A DNR must be signed
before a patient can
be admitted to hospice

52. Answer
False
However, the hospice team will educate,
provide counseling and clarify end-of-life
decisions with the patient and family

53. Considerations when
choosing a quality hospice
provider
• Rapid response time; same day admission
• Direct access to clinicians 24/7
• Ability to accept complicated cases & access
to an ethics committee
• Routine care staffing and frequency of visits

54. Considerations when
choosing a quality hospice
provider (Cont.)
• Continuous care staffing
• Death attendance
• Bereavement counseling/support groups
• Quality and process improvement systems
• Robust clinical system and outcome reporting

55. How Can You Make a
Difference?
• Become an advocate for quality end-of-life care
• Consider your own beliefs about advanced illness
and death
• Carry the tools that help you identify a terminal illness
• Evaluate the patient’s understanding of their condition
• Suggest an order evaluation for hospice care in
your treatment options when speaking with the
patient’s physician
Ask yourself—what does the patient want and
am I an advocate for his/her wishes?

56. For Additional Information:
NHPCO National Hospice &
Palliative Care Organization
www.nhpco.org

57. For Additional Information:
www.caringinfo.org
• Caring Connections is a national consumer and
community engagement initiative to improve care at
the end of life, supported by a grant from The Robert
Wood Johnson Foundation
• State-specific documents for advance care planning
are available

58. For Additional Information:
Duke University Institute
http://www.iceol.duke.edu/

59. Questions, Comments?

60. References
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Professional Nursing, 26(2), 125-132. doi:10.1016/j.profnurs.2009.12.009
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satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. Journal of The
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• Connor, S., Pyenson, B., Fitch, K., Spence, C., & Iwasaki, K. (2007). Comparing hospice and non-hospice patient
survival among patients who die within a three-year window. Journal of Pain & Symptom Management 33(3), 238-
246.
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61. References (Cont.)
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