Complex, chronically ill patients present an opportunity to discuss and implement hospice and palliative care. Many elderly patients who present to the ED and other busy practice settings are hospice-eligible because of functional decline and multi-morbidity. Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid time constraints and high-acuity challenges.

1. When Decision-Making Is Imperative:
Advance Care Planning for Busy Practice Settings
Eric S. Shaban MD | Regional Medical Director
VITAS®
Healthcare | eric.shaban@vitas.com

2. 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.

3. 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 01/31/2025.
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 – RT only receive
CE Credit in Illinois.

4. Objectives
After this presentation, learners should be able to:
• Identify the role and benefits of palliative care and hospice in the care
are continuum
• Know the elements of and how to implement a goals-of-care assessment
• Describe rapid palliative care assessment for busy practice settings
• Know how to leverage a goals of care assessment to drive patient care
• Understand the role that hospice providers (e.g., VITAS) can play in
the continuum of care for seriously ill patients

5. Redefining the Care Continuum
Medical decision-making is dichotomous
where treatments are curative/life-prolonging
or supportive/symptom-focused
Inter-related goals where life-prolonging and
supportive/symptom-focused can occur
concomitantly. Benefits from ongoing dialogue
around disease progression despite optimal
medical management
Curative
Onset of illness Death
Palliative
Curative
Onset of illness Death
Palliative

6. Goals of Care: Opportunities for Engagement
• Discusses, understands and
plans for future healthcare
decisions incorporating
one’s wishes and values
• Disease trajectory represents
common causes of death (cancer,
advanced lung and cardiac
diseases, dementia, etc.)
• Conversations should
occur throughout the
natural history of serious
illness, see below
Index presentation and hospitalization
introduce natural disease history and
concept of advance care plan
Acute exacerbations including ED visits
and hospitalizations; ongoing disease
education and help to complete an ACP
Annual Wellness
Visit
Assists in timely
transition to hospice
Quality
of
Life

7. 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 healthcare proxy
*Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable.
N = 332 *value < 0.001 **P value = 0.003
End-of-Life Discussions Align Care 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.

8. End-of-life discussions:
• Changed the care patients
received; care was
associated with a better
quality of life and death
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 173 (52.3) 80 (65.6) 93 (44.5) 1.65 (1.04-2.63) **
> 1 week
*P value = 0.02 **P value = 0.03
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.
• 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

9. Palliative Care in Busy Practice Settings
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
• The influx of medically complex,
chronically ill patients presents an
opportunity to enhance the role
of palliative care and hospice
• Many elderly patients who present
to the ED/hospital are hospice-
eligible, usually because of
functional decline and
multi-morbidity
• ED is not designed for end-of-life
(EOL) palliative discussions
– Time constraints and high-acuity
make lengthy conversations difficult
• Palliative care in ED/hospital
is changing
– ED palliative care specialists and
specialized geriatric EDs
are emerging

10. 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
• Clinicians establish GOC with patients daily
• Any team member can assess GOC

11. 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

12. 4 months ago
Presented to ED with
fall with abrasions
Patient:
JR is an 88 y/o with
advanced lung disease.
He resides in an ALF and
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 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

13. Advance Care Planning in the Emergency Department
Wang, 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
• 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
• This is a key opportunity to
begin conversations around
ACP and GOC

14. 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

15. Two Components of Goals of 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

16. Goals of Care Considerations
• Identify key practices to conduct
a goals-of-care conversation
• Describe a protocol to elucidate
goals of care
– Cure disease
– Prolong life
– Maintain or improve function
– Maintain or improve
quality of life
– Relieve burdens, support
loved ones
– Relieve suffering
• Accomplish personal milestones
– Attend important family events
– Go home
– Mend relationships
– Make peace with God
– Experience a good death
• Multiple goals often apply simultaneously
• Certain goals may be sacrificed to meet
other goals with greater priority
• Goals change; this is expected, and
ideally occurs gradually
• Explicitly include a goal of comfort
from the very first encounter

17. Two Components of Goals of 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

18. JR Case (cont.)
JR was diagnosed
with COPD
exacerbation and
treatment with
nebulizers, oxygen,
steroids, and
antibiotics
is started.
Patient’s daughter is called
and states that her father
has had significant decline
in the last year.
• He requires more help
at home is completely
dependent and spends
more 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

19. 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

20. Goals of Care
• Patients can have several goals of care
that at first glance, may seem contradictory:
– 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

21. 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:
– Prognosis
– Key healthcare transition points
– Disease severity
– Treatment options
– Patient’s wishes

22. 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

23. 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
• In an ideal situation, a GOC may
have been established. However,
a clinical change may present an
opportunity to re-address:
hospitalization, ED visit, ICU
admission, rehab/skilled care,
disease progression, new
symptoms, inability to tolerate
treatments, new goals

24. Functional Status Is an Important
Element of Prognostication
• 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
3. Disease-specific prognostication

25. Survival by Palliative Performance Score
(PPS) at Acute-Care Hospital
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.
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

26. 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

27. ABCD 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
• 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

28. ABCD Assessment (cont.)
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
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

29. Subacute Assessment – NEST
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
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?

30. Subacute Assessment – NEST (cont.)
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
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
Existential Needs
• Distress
• Worry/anxiety
• Dying words occur
in any setting
• Allow expression of
wishes, desires, hopes
• FICA
– Faith or beliefs
– Importance
– Community
– Address

31. 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…”

32. Fitting Rapid Assessment Into Busy Workflows
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
• 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

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

34. Challenges
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
• Time
• Provider discomfort
– Belief that this is outside area of expertise
– Limited training throughout medical education
• Fear of patient/family reaction
• Reimbursement not in line for time required

35. 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

36. The SPIKES Protocol
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.
SPIKES is an organized approach to delivering bad news and discussing GOC:

37. 5-Minute GOC Conversation
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

38. Facilitating the GOC Conversation: SPIKES Protocol
• 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

39. 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

40. 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

41. How to Introduce the Benefit
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
• Informational materials to help families understand the benefits of hospice:
– Hospicecanhelp.com
“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?”

42. 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

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

44. 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

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

46. 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

47. 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

48. 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

49. Impact
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
• 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 enrolled in hospice care

50. 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

51. Other Approaches
Add references and link
Reframe Expect
emotion
Map the
future
Align with
patient values
Plan
treatment

52. Other Approaches
Add references and link
Choose the approach that best fits your practice’s needs
Setup Understanding Priorities Explain Review and
Recommend

53. 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
Bell, D., (2018). Care of Geriatric Patients with Advanced Illnesses and End-of-Life Needs in the Emergency
Department. Clinics in Geriatric Medicine, 34(3), 453–467. https://doi.org/10.1016/j.cger.2018.04.008
Casarett, D., (2005). Improving the Use of Hospice Services in Nursing Homes. JAMA, 294(2), 211.
https://doi.org/10.1001/jama.294.2.211
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

54. References
Freund, K., (2012). Hospice Eligibility in Patients Who Died in a Tertiary Care Center (719). Journal of Pain and Symptom
Management, 43(2), 430. https://doi.org/10.1016/j.jpainsymman. 2011.12.197
Gade, G., et al. (2008). Impact of an Inpatient Palliative Care Team: A Randomized Controlled Trial. Journal of Palliative
Medicine, 11(2), 180–190. https://doi.org/10.1089/jpm.2007.0055
Gozalo, P., Hospice Enrollment and Evaluation of Its Causal Effect on Hospitalization of Dying Nursing Home Patients.
Health Services Research, 42(2), 587–610. https://doi.org/10.1111/j.1475-6773.2006.00623.x
Jencks, S., (2009). Rehospitalizations among Patients in the Medicare Fee-for-Service Program. Journal of Vascular Surgery,
50(1), 234. https://doi.org/10.1016/j.jvs.2009.05.045
Hospice Family Discussion Guide. (2021). VITAS Healthcare. https://www.vitas.com/hospice-and-palliative-care-basics/
when-is-it-time-for-hospice/hospice-family-discussion-guide
Masterson Creber, R., (2019). Use of the Palliative Performance Scale to estimate survival among home hospice patients
with heart failure. ESC Heart Failure, 6(2), 371-378pp 125-139.

55. References
Nelson, C. (2011). Inpatient Palliative Care Consults and the Probability of Hospital Readmission. The Permanente Journal,
15(2), 48–51. https://doi.org/10.7812/tpp/10-142
Palliative Practices: An Interdisciplinary Approach 1st Edition by Kim K. Kuebler, Mellar P. Davis, Crystal Moore (2005)
Paperback (1st ed.). (2021). Mosby
Physician comp is crucial to value-based care. Getting it right is hard. (2021, August 16). Gale Academic OneFile.
https://go.gale.com/ps/i.do?p=AONE&u=miam11506&id=GALE|A672582610 &v=2.1&it=r&sid=bookmark-AONE&asid=f5b05ba8
Sanoff, H., (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
Wang, D., (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