The goal of this webinar was to help hospice and healthcare professionals understand the history, philosophy, and practice of hospice and palliative care, including common misconceptions, typical diagnoses for hospice referrals, identification of hospice-eligible patients, reimbursement for hospice services, and the benefits of advance care planning and early referrals.

1. Hospice Basics and Benefits

2. CE Provider
Information
VITAS® Healthcare programs in California/Connecticut/Delaware/ Illinois/
Northern/Virginia/Ohio/Pennsylvania/Washington DC/ Wisconsin are provided
CE credit for their Social Workers through VITAS Healthcare Corporation,
provider #1222, is approved as a provider for social work continuing education
by the Association of Social Work Boards (ASWB) www.aswb.org, through the
Approved Continuing Education (ACE) program. VITAS Healthcare maintains
responsibility for the program. ASWB Approval Period: (06/06/18 - 06/06/21).
Social Workers participating in these courses will receive 1 clinical continuing
education clock hour. {Counselors/MFT/IMFT are not eligible in Ohio}.
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 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.

3. Goal
The goal of this presentation is to educate
nurses and other healthcare professionals
about hospice basics and hospice care’s
benefits for the patient and family.

4. Objectives
• Describe the history, philosophy, and
benefits of hospice
• List two or more criteria used to identify
the hospice-eligible patient and some
diseases commonly seen in end-of-life care
• Identify the difference between curative and
palliative care
• Explain Medicare reimbursement for hospice
• Discuss the relevance of advance directives
and do-not-resuscitate (DNR) orders when
discussing hospice services

5. Dying Then
and Now
19th Century:
• In 1900, 4% of America’s population was > 651
• In 1900, life expectancy was 49 years2
• Most people died at home
Today:
• Nearly 15% of the U.S. population is > 65 years3
• 2017 life expectancy in the U.S. was 78.7 years4
• Approximately 37% of Americans die in acute-
care hospitals and 19% die in nursing homes5
1Werner, C. (2011). The Older Population: 2010 US Census Bureau. Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf
2
Arias, E. (2003). United States Life Tables, 2003. US Centers for Disease Control and Prevention, National VITAL Statistics Reports, 54:14. Retrieved from https://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf
3United States Census Bureau (2017). Facts for Features: Older Americans Month, May 2017. Retrieved from: https://www.census.gov/newsroom/facts-for-features/2017/cb17-ff08.html
4Xu, J., et al. (2020). Mortality in the United States, 2018. NCHS Data Brief, January 2020. National Center for Health Statistics. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db355.htm
5
Xu, J. (2016). Percentage Distribution of Deaths, by Place of Death-United States, 2000-2014. US Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a6.htm

6. How People
Die
• < 10% die suddenly of an unexpected
event, heart attack (MI), accident, etc.
• > 90% die of a protracted,
life-threatening illness
– Predictable steady decline with a
relatively short “terminal” phase (cancer)
– Slow decline punctuated by periodic
crises (advanced cardiac disease,
advanced lung disease,
Alzheimer’s/dementia)
Emanuel, L., et al. (2003). The Education in Palliative and End-of-Life Care Curriculum
(EPEC Project). Northwestern University Feinberg School of Medicine.

7. Reinforcing
Hospice
Facts
Hospice is a place.
False. This is one of the commonly held
myths about hospice. Hospice care generally
takes place in the person’s home, whether a
private residence, nursing home, or assisted
living community. Some hospitals have
dedicated hospice beds, and some
communities have freestanding hospice
care centers or inpatient units.
However, the vast majority of people prefer
to spend their final days wherever they
call home.

8. Hospice
History
• Linguistic root words
– Hospital
– Hospitality
– Shelter
– Respite
– Caring
• A place of refuge and solace

9. Hospice
History
(cont.)
• 1967 Dame Cicely Saunders opened St.
Christopher’s in London
• 1969 book “On Death and Dying” by Elisabeth
Kubler-Ross brought topic into the mainstream
• 1974 New Haven Hospice of Connecticut established
• 1976 Hospice Care, Inc. (now VITAS) established
• 1978 National Hospice and Palliative Care
Organization (NHPCO) formed for those providing
care for advanced illness patients
– Mission: “To lead and mobilize social change
for improved care at the end of life”

10. Reinforcing
Hospice
Facts
You don’t need hospice until a few
days before you die.
False. Ideally, patients and families
choose hospice upon receiving a prognosis
of 6 months or less if the illness runs its
normal course. This affords the patient and
family the ability to receive optimal medical
management and symptom relief in the
comfort of their own home. Patients do not
need to be homebound to be eligible for
hospice services. NHPCO experts say the
ideal time for hospice care is 6 months.

11. A study of patients who self-reported mobility at 6-month intervals during the last 3 years of life provides insights
into theoretical trajectories of dying. Whether death was sudden or the result of organ failure, a terminal disease,
or frailty, the research identified trajectories along a scale from persistent disability to late decline.
Lunney, J., et al. (2018). Mobile trajectories at the end of life: Comparing clinical condition and latent class approaches. Journal of the American Geriatric Society, 66(3): 503-508. doi: 10.1111/jgs.15224.
0% 20% 40% 60% 80% 100%
Frailty
Organ
Terminal
Sudden
Percent of Each Clinical Group Belonging to Each Latent Trajectory Group
Late Progressive Moderate Early Persistent
Theoretical Trajectories of Dying

12. 28%
13%
13%
13%
8%
11%
14%
Days of Hospice Care per Patient 2018
1-7 days
8-14 days
15-30 days
31-60 days
61-90 days
91-180 days
>180 days
Proportion of
Patients by
Days of
Hospice Care
National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures

13. Hospice
Eligibility
• Advanced illness
• Medicare regulations
– Prognosis of 6 months or less
– Two physicians certify the patient as
being terminally ill with a life expectancy
of 6 months or less if the terminal illness
runs its normal course
• Patient and family have agreed to a care
plan with goals that are palliative in nature,
primarily focused on management of
physical, psychosocial, emotional, and
spiritual symptoms

14. 17.4
29.6
11
15.6
9.5
2.2
14.7
Heart
Disease
Cancer Respiratory Dementia Stroke Kidney Other
0
5
10
15
20
25
30
35
2018
Percentage
of Hospice
Patients
by Diagnosis
National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures

15. Reinforcing
Hospice
Facts
Hospice helps people with advanced
illness die more quickly.
False. In reality, just the opposite occurs.
Research published in the Journal of Pain
and Symptom Management found that
Medicare beneficiaries who opted for hospice
care lived an average of 29 days longer than
similar patients who did not take advantage
of hospice. Hospice improves quality of life
for patients with advanced disease.
Connor, S., et al. (2007). Comparing hospice and nonhospice patient survival among patients who
die within a three-year window. Journal of Pain and Symptom Management, 33(3), 238-246.

16. Curative Palliative
Disease-driven Symptom-driven
Doctor is in charge Patient is in charge
Disease process is primary
Disease process is secondary
to person
Few choices Many choices
Evidence-based treatments Comfort and quality of life
Curative
Care vs.
Palliative
Care

17. 14%
3%
5%
8%
70%
How knowledgeable are you
about palliative care?
Somewhat knowledgeable
Knowledgeable
Very knowledgeable
Don't know
Not at all knowledgeable
Consumer
Awareness
About
Palliative
Care
Fulmer, T., et al. (2018). Physicians’ views on advance care planning and end-of-life care conversations. Journal of the American Geriatrics Society, 66(6), 1201-1205.

18. What Is Palliative Care?
Cherny, N., et al. (2015). Oxford textbook of palliative medicine (5th ed.). Oxford University Press.
The study and management of patients
with active, progressive, far-advanced
disease for whom the prognosis is limited
and the focus of care is quality of life.
—Oxford Textbook of Palliative Medicine

19. Palliative
Care
• Manages pain and symptoms
• Regards dying as a normal process
• Neither hastens nor postpones death
• Integrates psychological and spiritual care
• Supports patient and family
• Incorporates a team approach
• Enhances quality of life
• Applicable early in the course of illness

20. Palliative
Care and
Hospice Care

21. Reinforcing
Hospice
Facts
Hospice is a last resort when nothing
else can be done. It is giving up!
False. When optimized medical treatments
can no longer cure a person who has an
advanced illness, hospice professionals
can do many things to:
• control symptoms and pain
• reduce anxiety
• offer spiritual and emotional support
• improve quality of life for patients with
advanced illness and their families

22. Non-
Oncology
Diagnoses
– Cardiac disease
(heart failure)
– Lung disease
(COPD,
emphysema)
– Alzheimer’s/
dementia and
other neurological
disease (chronic
and acute stroke)
– Sepsis
– Renal disease
– Liver disease
(end-stage
cirrhosis)
– ALS (Lou Gehrig’s
disease)
– AIDS
Medicare regulations
• End-stage and/or advanced:

23. Oncology
(Cancer)
Diagnoses
• Breast
• Bone
• Renal cell
• Pancreatic
• Bladder
• Glioblastomas
• Lung
• Colon
• Advanced prostate
with metastasis
• Head and neck
• Hematologic
malignancies

24. Disease
Progression
Decline in functional status:
– PPS ratings of < 50-60%
– Dependence in 3 of 6 ADLs
Deterioration in clinical condition
in the past 4-6 months:
– Multiple hospitalizations or
ED visits
– Decrease in tolerance to
physical activity
– Decrease in cognitive ability
• Other comorbid conditions
• Pain and difficulty breathing

25. Reinforcing
Hospice
Facts
Hospice discontinues all
medications and treatments.
False. Patients can continue treatments
that provide symptom relief and improve
quality of life.
• For example, a patient with advanced
lung disease who is currently on inhaler
therapy that allows them to breathe better
can continue this therapy while receiving
hospice care.

26. End-of-Life
Symptoms
Unrelieved pain
• Dyspnea
• Congestion
• Dysphagia
• Anorexia/cachexia
• Agitation/restlessness
• Confusion/delirium
• Disrupted sleep
• Nausea/vomiting
• Bowel obstruction

27. Reinforcing
Hospice
Facts:
True/False
Hospice administers morphine to hasten death.
False. When a patient is on hospice, a plan of care
is established together with the patient and family.
• This plan of care is individualized and based on
the patient’s specific physical and psychosocial
needs.
• Only if needed to relieve shortness of breath, pain,
or the active phase of dying, a hospice physician
can prescribe the lowest effective dose of
morphine to provide comfort.
• Not every patient on hospice requires or receives
morphine. Many other pharmacological and
nonpharmacological approaches are available.

28. End-of-Life
Symptoms
• Psychosocial
– Depression
– Anxiety
– Ineffective coping and communication
– Life-role transition
– Caregiver distress
• Spiritual
– Despair/hopelessness/isolation
– Powerlessness
– Lack of meaning
– Loneliness
– Need for reconciliation

29. Reinforcing
Hospice
Facts
If a patient chooses hospice, they will
lose their physician.
False. Hospice physicians and team
members work with the patient's doctor or
specialist to ensure clinical and emotional
needs are being met and that the patient’s
care is being carried out appropriately.
The patient’s personal doctor chooses his
or her level of participation in their care.

30. Medicare
Spending
and Hospice
National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures
$15.1 B $15.9 B $16.8 B $17.9 B $19.2 B
2014 2015 2016 2017 2018
Medicare Spending

31. 0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
In-hospital
Deaths
ICU Admissions 30-Day Hospital
Readmissions
Incremental
Reduction
in
Various
Outcomes
(Proportional)
53-105 days
15-30 days
8-14 days
1-7 days
Hospice
Impact
Kelley, A., et al. (2013). Hospice enrollment saves money for Medicare and improves care
quality across a number of different lengths-of-stay. Health Affairs, 32(3), 552-561.

32. Medicare
Hospice
Benefit
These services are mandated by the
Medicare hospice benefit
Interdisciplinary
Team of Hospice
Professionals
Home Medical
Equipment
Medication Bereavement
Support
Continuous
Care
Respite Care
Inpatient Care
Routine
Home Care

33. 85%
7%
5%
1%
1%
1%
Medicare Hospice Benefit
Private Insurance/Managed Care
Medicaid Hospice Benefit
Other Payment Source
Self-Pay
Charity or Uncompensated Care
Who Pays
for Hospice?
National Hospice and Palliative Care Organization. (2014). Facts & figures: Hospice care in America.
http://www.nhpco.org/sites/default/files/public/Statistics_Research/2014_Facts_Figures.pdf

34. Hospice
Interdisciplinary
Team
Patient and
Family
Volunteers
Physicians
Spiritual
Counselors
Social
Workers
Bereavement
Counselors
Hospice
Aides
Therapists
Nurses

35. Four Levels
of Hospice
Care
1. Routine home
care 89.81%
– Available wherever
the patient calls home
– “Basic” and
most frequently
delivered level
3. Inpatient care 6.44%
– For symptoms that
cannot be managed
in the home
2. Intensive Comfort Care®
(continuous care) 1.79%
– Medical management
in the home for up to
4 hours per day when
medically appropriate
4. Respite care 1.95%
– Provides a break for
primary caregiver
– Inpatient setting
– Limited to 5
consecutive
days and nights
National Hospice and Palliative Care Organization. (2020, August). Facts & figures: Hospice care in America. www.nhpco.org/factsfigures

36. Bereavement
• Hospice provides bereavement services
and offers grief and loss support for the
family after the patient dies
• For at least 1 year following a death,
hospice provides:
– Grief education resources, letters, cards
– Phone/Telehealth support and/or visits
if needed or requested by family
– Bereavement support groups
– Annual memorial activities
– Memory Bears

37. Reinforcing
Hospice
Facts
If a patient chooses hospice, they are
obligated to stay on service.
False. Hospice is a choice.
• Once a patient is on hospice, they can
revoke their hospice status at any time
for any reason.
• Patients can choose to return to hospice
so long as they meet eligibility guidelines.

38. Reinforcing
Hospice
Facts
A patient must have a do-not-resuscitate
(DNR) order to receive hospice services.
False. A patient is not required to have a
DNR when enrolling in a hospice program.
The hospice will, however, engage in goals-
of-care conversations with a patient and
family to align care goals with the hospice
philosophy of a peaceful passing at home.

39. Advance
Directives:
Defined
Advance directives are legal documents
that allow patients to formally state their
choices regarding what actions should
be taken or not taken regarding their
health in case they are no longer able to
make decisions for themselves because
of illness or incapacity.

40. Advance
Directives
• Studies show patients who had prepared advance
directives received care that was strongly associated
with their preferences.
• In 1990, Congress enacted the Patient Self-
Determination Act, mandating that all healthcare
providers who receive Medicare and Medicaid
funds must provide information regarding advance
directives to patients admitted to their programs.
• Advanced directives define the medical care a
patient wants or does not want to receive if he or
she becomes terminally ill and is mentally or
physically unable to communicate his or her wishes.
• Advance directives include living wills, durable power
of attorney, and designation of a healthcare surrogate.
Silveira, M., et al. (2010). Advance directives and outcomes of surrogate
decision making before death. New England Journal of Medicine, 362(13), 1211-1218.

41. Advance
Directives
and Hospice
• Patients are not required to have advance
directives in order to receive hospice care.
• Hospice staff will discuss the importance
of advance directives for preserving and
honoring patient choice.
• Hospice offers training on advance directives.
Advance directives preserve patient choice!

42. Hospice
Impact:
Satisfaction
• Hospice care is associated with better
symptom relief, patient-goal
attainment, and quality of EOL care.
• Families of patients enrolled in hospice
more often reported that patients
received “just the right amount” of pain
medicine and help with dyspnea.
• Families of patients enrolled in hospice
also more often reported that patients’
EOL wishes were followed and received
“excellent” quality EOL care.
• Families of patients who received
> 30 days of hospice care reported the
highest-quality EOL outcomes.
Kelley, A., (2013). Hospice enrollment saves money for Medicare and improves care
quality across a number of different lengths-of-stay. Health Affairs, 32(3), 552-561.

43. Conclusion
• Hospice is:
– A service, not a place
– Provided anywhere a person calls home
– Care that comforts and supports when
an advanced illness no longer responds
to cure-oriented treatments
– Making the most of the time that remains
– Covered by the Medicare hospice
benefit and most insurers

44. Partner With Hospice
“You matter because you are you. You matter
to the last moment of life, and we will do all we
can, not only to help you die peacefully, but
also to live until you die.”
—Dame Cicely Saunders
St. Christopher’s Hospice, London, England

45. Arias, E. (2003). United States Life Tables, 2003. US Centers for Disease Control
and Prevention, National VITAL Statistics Reports, 54:14. Retrieved from
https://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_14.pdf
Cherny, N., et al. (2015). Oxford textbook of palliative medicine (5th ed.).
Oxford University Press.
Connor, S., et al. (2007). Comparing hospice and nonhospice patient survival
among patients who die within a three-year window. Journal of Pain and
Symptom Management, 33(3), 238-246.
Emanuel, L., et al. (2003). The Education in Palliative and End-of-Life Care
Curriculum (EPEC Project). Northwestern University Feinberg School of Medicine.
Fulmer, T., et al. (2018). Physicians' Views on Advance Care Planning and
End-of-Life Care Conversations. Journal of the American Geriatrics Society,
66(6), 1201-1205.
Kelley, A., et al. (2013). Hospice enrollment saves money for Medicare and
improves care quality across a number of different lengths-of-stay. Health Affairs,
32(3), 552-561.
Lunney, J., et al. (2018). Mobile trajectories at the end of life: Comparing clinical
condition and latent class approaches. Journal of the American Geriatric Society,
66(3): 503-508. doi: 10.1111/jgs.15224.
References

46. References
National Hospice and Palliative Care Organization. (2020, August). Facts &
figures: Hospice care in America. www.nhpco.org/factsfigures
National Hospice and Palliative Care Organization. (2014). Facts & figures:
Hospice care in America. http://www.nhpco.org/sites/default/files/public/
Statistics_Research/2014_Facts_Figures.pdf
Silveira, M., et al. (2010). Advance directives and outcomes of surrogate decision
making before death. New England Journal of Medicine, 362(13), 1211-1218.
United States Census Bureau. (2017). Facts for Features: Older Americans
Month, May 2017. Retrieved from: https://www.census.gov/newsroom/
facts-for-features/2017/cb17-ff08.html
Werner, C. (2011). The Older Population: 2010 US Census Bureau.
Retrieved from https://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf
Xu, J. (2016). Percentage Distribution of Deaths, by Place of Death-United
States, 2000-2014. US Centers for Disease Control and Prevention. Retrieved
from https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a6.htm
Xu, J., et al. (2020). Mortality in the United States, 2018. NCHS Data Brief,
January 2020. National Center for Health Statistics. Retrieved from
https://www.cdc.gov/nchs/products/databriefs/db355.htm