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

1. Advanced Cancer
and End of Life

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 01/31/2025.
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. • 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.
Goal

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. Patients with advanced Stage III/IV metastatic
cancers who have not responded to first-line
antitumor therapies, despite an oncologist’s
best efforts to optimize treatment, may be
eligible for hospice.
Advanced Cancer Hospice Eligibility Guidelines
*ECOG 2: Generally hospice eligible although may also be appropriate for more antitumor treatment.
**ECOG 3: Generally hospice eligible and not appropriate for more antitumor treatment (side effects of treatment greater than clinical benefit).
The Eastern Cooperative Oncology Group (ECOG)
performance status scale is a 6-point scale used to
assess how a patient’s cancer affects their daily life
and ability to function as detailed below.
An ECOG score of 3 or higher correlates roughly
with life expectancy of 3 months or less:
And 0: Asymptomatic
1: Symptomatic but completely ambulatory
2: Symptomatic, <50% in bed but not bedbound*
3: Symptomatic, >50% in bed but not bedbound**
4: Bedbound
5: Death
Supportive Features (ANY)
• Unintentional weight loss
• Uncontrolled nausea,
vomiting, constipation
• Uncontrolled pain
• Uncontrolled dyspnea
• Due to uncontrolled symptoms, has difficulty
getting to oncologist appointment and/or
has frequent hospitalizations
• Uncontrolled anxiety due
to shortness of breath

7. Case Study of MK

8. Case Study of MK
Patient
67-year-old male who presented to
his PCP with cough, shortness of breath
with exertion, mild to moderate left
shoulder pain within the last month
Medical History
Hypertension, hyperlipidemia,
ex-smoker (quit 5 years ago), COPD,
oxygen-dependent
Social History
Married, wife is primary
caregiver, one adult daughter, one
9-month-old grandson, works at a
T-shirt printing company
Diagnostic Workup
• In the 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

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
Status Post 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. What Does the
Evidence Say?

18. N = 1,655
Prognostication Tools in Advanced Cancer:
The Role of Functional Status
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
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)

19. • 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 Plan of Care (POC) for MK

20. Wright, 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 Care
With Patients’ Wishes and Values
7.3
6.5
7.3
7.4
7
7.2
0
2
4
6
8
10
Depressed Nervous or worried Sad
McGill Psychological Subscale
With ACP Without ACP
52.9%
48.8%
63.0%
71.7%
28.7% 27.8% 28.5%
46.1%
0
20
40
60
80
100
Accepts illness is
terminal
Against death in
ICU
Completed DNR
order
Completed living
will, durable power
of attorney, or
healthcare proxy
Acceptance, Preferences
With ACP Without ACP
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

21. End-of-Life Discussions Align Treatments
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.
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

22. Example of Hospice Care Model for Oncology Patients

23. • 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
Hospice as Active Plan of Care for MK
– 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

24. • 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
• RN visits MK three times weekly
• Increased respiratory distress noted
despite titrating oxygen; transitioned
to high-flow O2 by respiratory
therapist (RT)
Hospice as Active Plan of Care for MK

25. • 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 for MK

26. • Social worker visits, reviews concerns
of MK and his family, identifies that
wife is struggling
– Counseling is arranged as follow-up
• 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
• 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 as Active Plan of Care for MK

27. Early Palliative Care Impacts Survival
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.

28. • 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 titrated
– Social worker and chaplain
revisit with MK’s wife
Hospice as Active Plan of Care for MK

29. • 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 for MK

30. Additional Evidence in
Support of Hospice Care

31. 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
*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.
The Medicare Hospice Benefit Is a 6-Month Benefit: Quality
and Cost Evidence Corroborate the Need for Timely Access

32. Comparison of Total Costs of Care by Disease Group and
Hospice Episodes in the 12-Month Period Before Death*
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
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.

33. The Benefits of Hospice for Patients Living With Cancer:
The Value Proposition
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.
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

34. 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.

35. Ongoing Demonstration of Hospice Quality
Advantage to Patient, Families, and Caregivers
Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ Supportive & Palliative Care, 9(1), e13-e13.
Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830.
Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved caregivers’ mental health. Journal of Clinical Oncology, 28(29), 4457.
Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432.
Families remarked patients received
just the right amount of pain medicine
and help with dyspnea
Families of patients receiving >30
days of hospice reported the most
positive EOL outcomes
Families more often reported patients’ EOL
wishes were followed and rated quality of
EOL care as excellent
Family
Less risk for PTSD
with home hospice
deaths**
Home hospice reduced risk
for prolonged grief disorder***
Hospice admission in last 6 months of
life correlated with increases in patient
satisfaction and better pain control,
reductions in hospital days
Less physical and emotional
distress and better quality of
life at EOL*
Caregivers
Patients
Hospice beneficiaries saw
a cost savings of $670 in
out-of-pocket expenses during
the last month of life compared
to non-hospice users
*Cancer patients, when comparing death in hospital to death in hospice **Compared to death in ICU ***Compared to hospital deaths
60% reduction in end-of-life transitions, allowing patients to die in location of choice

36. Questions?

37. The VITAS mobile app includes helpful
tools and information:
• Interactive Palliative Performance
Scale (PPS)
• Body-Mass Index (BMI) calculator
• Opioid converter
• Disease-specific hospice
eligibility guidelines
• Hospice care discussion guides
We look forward to having you
attend some of our future webinars!
Additional Hospice Resources
Scan now to
download the
VITAS app.

38. Harrison, et al. (2022). Hospice Improves Care Quality For Older Adults With Dementia In Their Last Month Of Life: Study
examines hospice care quality for older adults with dementia in their last month of life. Health Affairs, 41(6), 821-830.
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.
Kleinpell, et al. (2019). Exploring the association of hospice care on patient experience and outcomes of care. BMJ
Supportive & Palliative Care, 9(1), e13-e13.
Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology,
35(4), 432.
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
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.
References

39. 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.
Wright, et al. (2010). Place of death: correlations with quality of life of patients with cancer and predictors of bereaved
caregivers’ mental health. Journal of Clinical Oncology, 28(29), 4457.
References

40. 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.