Advance Care Planning in the ED

When Decision-Making
Is Imperative: Advance
Care Planning in the ED
Eric S. Shaban MD | Regional Medical Director
VITAS®
Healthcare | eric.shaban@vitas.com

CME Provider Information
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.

CE Provider Information
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 – RT only receive CE Credit in Illinois.

Objectives
• Identify the role of palliative care and hospice in the emergency
department (ED)
• Identify patients who would benefit from hospice or palliative care
• Know the elements of palliative care assessment
• Describe rapid palliative care assessment for stable and unstable patients
• Know how to use a palliative care assessment to drive a care plan
• Conduct and integrate rapid palliative care assessments
• Understand the role that hospice providers (e.g., VITAS) can play
in the continuum of care for ED patients
After this presentation, learners should be able to:

Palliative Care in the Emergency Department
• The influx of medically complex, chronically ill patients presents an
opportunity to enhance the role of palliative care and hospice in the ED
• Many elderly patients who present to the ED are hospice-eligible,
usually because of functional decline and multi-morbidity
• ED is not designed for end-of-life (EOL) and palliative discussions
– Time constraints and high-acuity make lengthy conversations difficult
• Palliative care in ED is changing ED palliative care specialists and
specialized geriatric EDs are emerging
ABIM Foundation. (2015). American College of Emergency Physicians. Choosing Wisely | Promoting Conversations between Providers and Patients. Retrieved from:
https://www.choosingwisely.org/clinician-lists/american-college-emergency-physicians-delaying-palliative-and-hospice-care-services-in-emergency-department/
Lamba, S., & Quest, T. E. (2011). Hospice Care and the Emergency Department: Rules, Regulations, and
Referrals. Annals of Emergency Medicine, 57(3), 282–290. https://doi.org/10.1016/j.annemergmed.201

American College of Emergency Physicians
Choosing Wisely Recommendations
• Palliative care is medical care that provides comfort and relief of
symptoms for patients who have chronic and/or incurable diseases.
Hospice care is palliative care for those patients in the final few
months of life.
• Emergency physicians should engage patients who present to the
emergency department with chronic or terminal illnesses; referral from
the emergency department to hospice and palliative care services can
benefit select patients resulting in both improved quality and
quantity of life.
https://www.choosingwisely.org/societies/american-college-of-emergency-physicians/
Don’t delay engaging available palliative and hospice care services
in the ED for patients likely to benefit.

The Importance of Goals of Care
• Patients’ values are honored
• Symptoms are attended to quickly and effectively
• Patient and family maintain control of treatment plan
• Poorly defined goals can lead to:
– Unwanted treatments
– Inappropriate use of resources
– Undue suffering
– Miscommunication
• Emergency clinicians establish GOC with patients daily
• Any team member can assess GOC

ACP Is Not About a Piece of Paper
• Advance care planning is about life philosophies, goals,
preferences, priorities, family understanding, and support
• It is about preventing suffering for the patient’s family, as much
as or more than, the patient by helping them see the road ahead
• Uses windows of opportunity to address different and changing
aspects of a patient’s/family’s care goals over time

4 months ago
Presented to ED with
fall with abrasions
Patient:
JR is an 88 y/o with
advanced lung disease.
Daughter lives locally
and is decision-maker
Medical History
COPD for 20 years,
60-pack/year smoking
history, HTN, NIDDM
diet controlled, PVD.
Past history of severe
COPD on O2, HTN, and
advanced dementia
Symptoms
Labored breathing at
28 BPM, O2 sat of 88% 4L,
wheeze, occasional cough,
cachectic appearing, and is
confused, picking at sheets
and not following commands
2 months ago
Observation stay for
COPD exacerbation
and delirium
6 months ago
Hospitalized for severe
COPD exacerbation
with admission to ICU
on BiPAP has been in
SNF since D/C
Typical Clinical Presentation SNF to ED
Now
Brought into the ED
by ambulance from
SNF for altered
mental status and
shortness of breath
Treatments
Disease-directed therapy
with Spiriva, Advair, and
chronic oxygen therapy.
Receives some benefit
from nebulizer and uses
it “a few” times a day

Advance Care Planning in the
Emergency Department
• The ED has a unique opportunity to serve as a hub for unmet
palliative care needs
• Palliative care and hospice referrals can reduce ED
utilization and hospitalization by as much as 50%
• GOC discussions in ED with appropriate hospice and palliative
referrals can benefit the patient and healthcare system
• Patients who have the opportunity to interact with hospice and
palliative care have higher satisfaction scores
1Wang, D. H. (2017). Beyond Code Status: Palliative Care Begins in the Emergency Department.
Annals of Emergency Medicine, 69(4), 437–443. https://doi.org/10.1016/j.annemergmed.2016.10.027

Advance Care Planning in Busy Practice Settings
• Busy practice settings like the ED and hospital are important
settings where primary palliative care can be provided by
any clinician to include:
– Facilitating basic GOC conversations
– Facilitating basic treatment decisions
– Providing basic pain and symptom management
• “Lack of time” is the most common reason cited by physicians
for not engaging in these conversations

Two Components of Palliative Care Assessment
1. First: Identify the patient’s prognosis
• The “surprise question” is the easiest and most predictive
“Would I be surprised if the patient
were to die in the next 12 months?”
“Would it surprise me if the patient
were to die in the next 6 months?”
“Would it surprise me if the patient
were to die during this admission?”
Many times, a life-limiting illness
or significant disease progression
is diagnosed in the ED

Two Components of Palliative Care Assessment
2. Second: Elicit the patient’s and family’s goals of care
• Patients and families are more capable of making decisions
about treatment goals than about treatment interventions
• Patients and families desire honest, compassionate
communication about prognosis and appropriate
treatment options
– Feel comfortable making recommendations
to patients and families

JR was diagnosed
with COPD
exacerbation and
treatment with
nebulizers, oxygen,
steroids, and
antibiotics
is started.
JR Case (cont.)
Patient’s daughter is
called and states that her
father has had significant
decline in the last year.
• He is completely
dependent and
spends most of
his time in bed.
• Her goals for JR are
for comfort, to have
easy things treated,
no heroic measures,
and to try and stay
out of the hospital.
Disposition options
for JR include:
• Admission
• Observation
• Return to SNF
with DNH/DNR
• Return to SNF
with hospice
services

Goals of Care: Introduction
• Goals of care:
– Are personal
– Drive intervention choices
– May change over time
• GOC processes can be
used at any time during
a person’s illness

Goals of Care
• Multiple, sometimes contradictory goals may apply simultaneously
– Communicate to find balance
– Curative and palliative paths can coexist
• Allows for some treatment to continue rather than changing
the goal
• Goals may change
– Some take precedence
• The shift in focus of care:
– Is gradual and is an expected part of the continuum of medical care

As you are considering options
for JR, you are interrupted to
attend to another patient, SM.

Patient:
SM is 93 y/o and lives
with son. She is in
severe respiratory
distress brought to
ED by EMS on NRB
mask. She is awake,
alert, and oriented and
has no advanced
directives in place
Medical History
This is SM’s second ED visit in 3M
for CHF. She sees her cardiologist
monthly for heart failure, has had
multiple adjustments to her diuretics,
and is using oxygen at home. She
is unable to dress or bathe herself
due to SOB. She nods off frequently
throughout the day and spends most
of day in recliner chair or resting in bed
Symptoms
She has O2 sat of 90%,
3+ edema to her lower
extremities, ales, pulse
115 sinus, and BP of
160/90. EKG shows
tachycardia, troponins
negative, elevated
BNP, and CXR
consistent with CHF
Typical Clinical Presentation – Home
to ED With Son
Treatments
IV Furosemide
is initiated
As you are considering options for JR, you are interrupted for another patient:
Today
SM’s son John arrives and says mom has been declining
in last year. Their goals are to remain out of the hospital if
possible but need more help in the home.
Is a goals-of-care discussion
warranted in this case? Yes.

Goals of Care and Advance Care Planning
• GOC and ACP constantly evolve with patients’ clinical status
• Multiple opportunities to address GOC and ACP throughout
the disease process are impacted by:
– Disease severity
– Prognosis
– Treatment options
– Patient’s wishes

GOC and ACP Early in Diagnosis
• When presenting a patient with a diagnosis of a serious/advanced
illness, take the opportunity to address and document some
basic and “easy” care goals
– The proxy: “If you were ever unable to make decisions for
yourself, who knows you the best and who would you want
to make decisions for you?”
– The line in the sand: “There are a lot of things that we
doctors can do for you. Is there anything that you would
find completely unacceptable?”
• Based on response, this may require clarification and
further exploration

GOC and ACP as Disease Progresses
• Patients who progress through life-limiting illnesses often have
undergone numerous surgical and medical interventions
• Wishes change based on:
– Illness course
– Past response to treatment
– Functional decline
– Symptom burden
• Whenever there is a clinical change, ideally re-address:
hospitalization, ED visit, disease progression, new symptoms,
inability to tolerate treatments, new goals

• As functional status declines, so does prognosis
• The rate of decline affects prognosis
• Several validated scales can help measure functional
status over time
• Several available performance tools. Here we cover:
1. Basic ADL decline (3 out of 6)
2. Palliative Performance Scale (PPS)
• Spending >50 of waking hours lying or resting
(ALZ Mod 2)
3. Disease-specific prognostication
Functional Status Is an Important
Element of Prognostication

Survival by Palliative Performance Score
(PPS) at Acute-Care Hospital
PPS
Score
Ambulation
Activity and
Evidence
of Disease
Self-Care Intake
Conscious
Level
60 Reduced
Unable to do
hobby/housework
Significant
disease
Occasional
assistance
necessary
Normal
or
reduced
Full or
confusion
50
Mainly
sit/lie
Unable to do
any housework
Extensive
disease
Considerable
assistance
required
40
Mainly
in bed
Unable to do
most activities
Extensive
disease
Mainly
assistance
Full or
drowsy
+/-
confusion
30
Totally
bedbound
Unable to do
any activities
Extensive
disease
Requires total
care
• Patients with a PPS score of ≤ 50 are generally
hospice-eligible; some patients with a higher
PPS may also be eligible
Masterson Creber, R., et al. (2019). Use of the Palliative Performance Scale to Estimate Survival Among Hospice Patients With Heart Failure. ESC Heart Failure, 6(2), 371-378.

Functional Decline Trajectory
ADL
Dependency
High
Slow Decline Over Time
Low
ADL Dependency and Disease-Related Complications
Disease-related
complications include,
but are not limited to:
• UTI
• Sepsis
• Febrile episode
• Delirium
• Pneumonia
• Hip fracture
• Difficulty eating or
dysphagia
• Dehydration
• Feeding tube (decision)
Disease-related
complication;
dependence in
5/6 ADLs
Death
Disease-related
complication;
dependence in
2/6 ADLs
Disease-related
complication;
dependence in
1/6 ADLs
Hospice-Eligible
• Dependence in 3/6
ADLs (bathing, dressing,
feeding, continence,
ambulation, transferring)
• Disease-related
complication
within last 6 months

Rapid Palliative Care Assessment
• Seeks to ascertain all relevant, illness-related needs
• Critical patient key decision points focused on the treatment:
– Intubate?
– ICU?
• A stable patient setting allows for more thorough assessment
Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine:
Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html

ABCD Assessment
• Covers physical and psychosocial domains
• If patient stabilizes, move to subacute assessment
For patients who are acute, unstable, or critical:
Advance
care
planning
Caregivers
to
consider
Make the
patient
feel Better
Decision-
making
capacity

Advance Care
Planning
Feel Better
• Rapid assessment
and treatment
of symptoms
– Dyspnea
– Delirium
– Pain
• Relief of critical/
unstable distress
also decreases
suffering, stress,
and anxiety for
the patient and
family caregivers
Caregivers
• Involve early
• Valuable information
source
• Legally authorized
surrogate
• Who called
for help?
• Why?
Decision-Making
Capacity
• Can the patient:
– Receive information?
– Process and understand
the information?
– Deliberate?
– Make, articulate, and
defend a choice?
• Decision-making
capacity can exist
in the setting of
unstable vitals
ABCD Assessment (cont.)

Subacute Assessment – NEST
What should the
Therapeutic
goals be for
this or
hospitalization?
Are there
social Needs
that can
guide post-ED
disposition and
prevent repeat visits?
Does the
patient have
Existential needs
that mandate
attention from
ED providers?
Which Symptoms,
physical or
psychological,
require treatment
during this visit?

Social Needs
• Access to care
• Caregiving
• Closeness vs.
personal isolation
• Financial issues
• Consider engaging
social worker
colleagues
Symptoms
• Physical symptoms
• Mental symptoms
– Harder to identify
Therapeutic
• Goals of care
• Health information
• Therapeutic
relationship
• Treatment plan
Subacute Assessment – NEST (cont.)
Existential Needs
• Distress
• Worry/anxiety
• Dying words occur
in any setting
• Allow expression of
wishes, desires, hopes
• FICA
– Faith or beliefs
– Importance
– Community
– Address

Addressing Code Status
• As patient enters the advanced illness phase of a disease, it becomes
important to address code status and advanced life support
• With effective, ongoing GOC communication, a provider can address these
treatments in a timely manner and prevent unintentional harm to patient
– “Has anyone spoken to you in regard to your wishes about things like
CPR and life support?”
– “What is your understanding of these interventions?”
– “We want to expect the best but prepare for the worst as well.”
• When appropriate, make recommendations:
– “At this point in your illness we only want to do things that will make sense.
Things like CPR and intubation will likely only cause you harm, and if you
did come out of it, you likely would not be as functional as you are now.
I would recommend putting some limits there…”

Fitting Rapid Assessment Into the ED Workflow
• Allow for interdisciplinary involvement in the assessment
– Delegate appropriate domains to save time
• Recommend an optimal care plan
• Coordinate interdisciplinary care
– Requires a team approach
– Must hear and respect evaluations and assessment
of each member
– Neither realistic nor necessary for any single provider
to assess and address all domains of suffering

ED Interdisciplinary Team
• Prehospital care
• Triage/bedside nurse
• Physician/nurse practitioner/physician assistant
• Ancillary ED providers
• Chaplains
• Social worker
• Case manager/coordinator

Challenges
• Time
• Provider discomfort
– Belief that this is outside area of expertise
– Limited use of ED team/referrals
• Reimbursement not in line for time required

Communicating Serious Illness
• A number of clinical tools exist to deliver bad news and facilitate
GOC conversations
• SPIKES method (for stabilized patients) is in-depth and organized.
However, it can require significant time from the clinician
– Difficult to implement in ED
– There are some important takeaways from the protocol
• 5-minute GOC conversation in the ED (for all patients)
– Fine-tuned to the fast-paced ED environment
– Helps to rapidly assess patient’s GOC and disposition to
hospice and palliative care

The SPIKES Protocol
SPIKES is an organized approach to delivering bad news and discussing GOC:
Baile, W., et al. (2000). SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5(4), 302–311.

5-Minute GOC Conversation in ED
Elicit patient’s understanding
of underlying illness and
today’s acute change
If available, build
on previous advance
directives or documented
conversations
Acquire a sense of the
patient’s values and
character, to help
frame prognosis and
priorities for intervention
Name and validate the
patient’s observed goals,
hopes, fears, and
expectations
Minutes
1–4
Discuss treatment
options, using
reflected language
Continually re-center
on patient’s
(not family’s) wishes
and values
Recommend a course
of action, avoiding
impartiality when the
prognosis is dire
Minutes
3–4
Introduce ancillary
ED resources
(e.g., hospice,
observation,
social work, chaplain)
Summarize and
discuss next steps
Minutes
5

• It is often necessary to use components of the SPIKES and
5-Minute Clinical Consult to effectively meet the needs
of patients and families
• Do not forget to utilize other team members when facilitating
GOC discussions
– Bedside nurse
– Care coordinator/case manager
– Social worker
– Chaplain
Facilitating the GOC Conversation:
SPIKES Protocol

Introducing Hospice
• Save the “hospice” word until the end of the conversation
• Focus on the services and benefits of hospice for
patients and their families
• Focus on the team approach and value of hospice’s interdisciplinary
team members
• Focus on the benefits of expert symptom management in the
patient’s preferred setting
• Focus on the Medicare (Part A) hospice benefit, which pays up to
100% of costs related to each patient's hospice diagnosis, including
medical care, equipment, medications, and supplies

Reinforce Facts About Hospice
• Introducing hospice to patients and families is a challenge
• There are many patient and provider misunderstandings about
hospice services:
– Myth Hospice is a NOT a place. It is a range of resources
focused on comfort and quality of life
– Myth Hospice is NOT solely for patients who are actively dying;
eligible patients have a prognosis of 6 months or less if the
disease runs its normal course; care can continue beyond
6 months if eligibility is met
• Overcoming these barriers requires communication with
care and empathy

How to Introduce the Benefit
• Informational materials to help families understand the benefits of hospice:
– Hospicecanhelp.com
Hospice Family Discussion Guide. (2021). VITAS Healthcare. Retrieved from:
https://www.vitas.com/hospice-and-palliative-care-basics/when-is-it-time-for-hospice/hospice-family-discussion-guide
“What if I told you there was a benefit available to your loved one
at this point of his/her illness that covered the medications related
to his/her illness, any medical equipment (s)he may need, nursing,
aide, and physician services, and all this is provided in the home.
Would you be interested in hearing more about these services?”

Hospice Care
• Interdisciplinary team-oriented approach to EOL care
– Patient- and family-centered care
– Goals of care/shared decision-making
• Aggressive care near the end of life: medical care, pain and
symptom management, and emotional and spiritual support
• Provided in any setting
• 4 different levels of care, based on each patient’s clinical needs

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
Routine
Home Care
Inpatient Care

Continuous Care
Higher level of care
• Acute symptom management
• Patient’s bedside/preferred care setting
• VITAS RN/LPN/LVN/aide
• Temporary shifts of 8-24 hours until
symptoms stabilize
• Prevents ED visits/hospital readmissions
Respite Care**
• Provides temporary break (caregiver
burnout, travel, work, etc.)
• Up to 5 days and nights of 24-hour
patient care
• Medicare-certified hospital, hospice
facility, or long-term care facility
Routine Care
• Most common level of hospice care
• More robust and comprehensive
compared to home health care services
• Patient’s preferred setting
• Proactive clinical approach helps
prevent ED visits/hospital readmissions
Four Levels of Care
*Per Medicare guidelines, these 2 levels of care are provided on a temporary basis
until the symptom(s) is optimally managed.**Usually not offered more than monthly
General Inpatient (GIP) Care*
• Higher level of care (GIP/VITAS IPU)
• Acute symptoms can no longer be
managed in patient’s preferred setting
• VITAS RN/MD/psychosocial team
• Temporary until symptoms stabilize
• Prevents ED visits/hospital readmissions

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

Patient Identification
Does the patient have advanced illness or multimorbidity
(e.g., advanced COPD, metastatic cancer, CHF, dementia, frailty)?
Does the patient spend ≥ 50% of daytime hours sitting or resting
(PPS ≤ 50)?
Has the patient visited the ED or hospital 2+ times in the last 6 months?
Do you think this patient could die within the next 6-12 months
or during this visit?
Has the patient experienced ≥ 10% weight loss in last 6 months?
Recurrent falls with injury? Ongoing symptoms related to their
terminal illness?
Hospice Eligibility Identification Questions

General Hospice Guidelines: Significant Predictors
of Poor Prognosis
• Dependent in 2-3
of 6 ADLs
• Confined to bed
or chair > 50%
of waking hours
• SOB or fatigue at
rest/minimal exertion
• Multiple ED visits
or hospitalizations
• 10% weight loss
in 6 months
• Recurrent falls
with injury
• Decreased tolerance
to physical activity
General Guidelines
• NYHA Class III/IV:
– Fatigue
– Angina
– Palpitations
– Dyspnea at
rest and/or with
minimal exertion
• ED visits,
hospitalizations
within last 6 months
• Not a surgical
candidate
Advanced Cardiac Disease•

General Hospice Guidelines: Significant Predictors
of Poor Prognosis (cont.)
Advanced Lung Disease
• 3/6 ADL dependency
• Clinical complication:
– Pneumonia
– UTI
– Sepsis
– Weight loss 10%
– Two stage 3-4
pressure ulcers
– Hip fracture
– Swallowing difficulty
– Feeding tube
decision
– Delirium
Alzheimer’s/Dementia
• Disabling dyspnea
– SOB at rest and/or
with minimal exertion
• Oxygen-dependent
plus
• Disease progression
with either:
– ED visits or
hospitalizations
in past 6 months
– Cor pulmonale

Impact
• Literature now showing that hospice utilization:
– Lowers rate of hospitalization and ED visits
– Lowers rate of ICU utilization
– Lowers rate of in-hospital death
• Similar evidence has been demonstrated with chronic illnesses:
– Hospitalization 88% less likely for heart failure patients
enrolledin hospice care
Kheirbek, R., et al. (2015). Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure.
Circulation: Heart Failure, 8(4), 733–740. https://doi.org/10.1161/circheartfailure.115.002153 Sanoff, H., et al. (2017). Hospice Utilization and Its Effect on Acute Care
Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma. Journal of Oncology Practice, 13(3), e197–e206. https://doi.org/10.1200/jop.2016.017814

How VITAS Can Help
Services VITAS Home Health
Nurse 24-Hours a Day ✓ Variable
Nurse Frequency of Visits Unlimited Diagnosis Driven
Palliative Care Physician Support ✓ X
Medications Included ✓ X
Equipment Included ✓ X
Levels of Care
Home, Inpatient,
Respite, Continuous
Home
Bereavement Support ✓ X
Primary Care/Specialty Visits ✓ ✓
Targeted CHF Program ✓ Variable
Care Plan Review Weekly Variable

How VITAS Can Help
• Cost savings are achieved through high-quality, comprehensive
coordinated care at home
• Increased visit frequency with hospice allows for earlier identification and
management of symptoms in place
• Ability to manage patients who require high-acuity care
• Higher likelihood of patients dying in their preferred location: home
– 70% of Americans with a life-limiting diagnosis report wishing to
die at home with family and loved ones
Hamel, L., (2017). Views and Experience with End-of-Life Medical Care in the U.S. Kaiser Family Foundation.
Retrieved from: https://www.kff.org/report-section/views-and-experiences-with-end-of-life-medical-care-in-the-us-findings/

References
Abbott, J. (2019). The POLST Paradox: Opportunities and Challenges in Honoring Patient End-of-Life
Wishes in the Emergency Department. Annals of Emergency Medicine, 73(3), 294–301.
https://doi.org/10.1016/j.annemergmed.2018.10.021
ABIM Foundation. (2015). American College of Emergency Physicians. Choosing Wisely | Promoting
Conversations between Providers and Patients. https://www.choosingwisely.org/clinician-lists/american-
college-emergency-physicians-delaying-palliative-and-hospice-care-services-in-emergency-department/
Baile, W., (2000). SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with
Cancer. The Oncologist, 5(4), 302–311. https://doi.org/10.1634/theoncologist.5-4-302
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