CHAPTER- 1 SEMESTER V NATIONAL-POLICIES-AND-LEGISLATION.pdf
When Decision-Making Is Imperative: Advance Care Planning in the ED
1. When Decision-Making
Is Imperative: Advance
Care Planning in the ED
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 01/31/2023.
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.
4. 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:
5. 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
6. 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
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.
7. 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
8. 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
• Use windows of opportunity to address different and changing
aspects of a patient’s/family’s care goals over time
9. 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
4 months ago:
Presented to ED with
fall with abrasions
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
10. Advance Care Planning in the
Emergency Department
• The ED has a unique opportunity
to serve as a hub for unmet
palliative care needs1
• 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
11. 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
12. 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
13. 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
14. JR was diagnosed
with COPD
exacerbation and
treatment with
nebulizers, oxygen,
steroids, and
antibiotics
are started.
JR Case (cont.)
Patient’s daughter is
called who 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 hospital.
Disposition options
for JR include:
• Admission
• Observation
• Return to SNF
with DNH/DNR
• Return to SNF
with hospice
services
15. 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
16. 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
– Is an expected part of the
continuum of medical care
17. As you are considering options
for JR, you are interrupted to
attend to another patient, SM.
18. 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, 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 hospital if
possible but need more help in the home.
Is a goals-of-care
discussion
warranted in
this case? Yes.
19. Goals of Care and Advanced 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
20. 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 to you. Is there anything that you would
find completely unacceptable?”
• Based on response, this may require clarification and
further exploration
21. 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
22. • 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)
3. Disease-specific prognostication
Functional Status Is an Important
Element of Prognostication
23. 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.
24. 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
25. Rapid Palliative Care Assessment
• Seeks to ascertain all relevant, illness-related needs
• In an unstable/critical patient, the assessment
addresses only enough to direct the
appropriate treatment
• 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
26. ABCD Assessment
• For patients who are acute, unstable, or critical:
– Advance care planning
– Make the patient feel Better
– Caregivers to consider
– Decision-making capacity
• Covers physical and psychosocial domains
• If patient stabilizes, move to subacute 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
27. Feel Better
• Rapid assessment and treatment
of symptoms
– Dyspnea
– Pain
– Delirium
• Relief of critical/unstable distress also
decreases suffering, stress, and anxiety
for the patient and family caregivers
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
28. Caregivers
• Involve early
• Valuable information source
• Legally authorized surrogate
• Who called for help?
• Why?
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
29. 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
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
30. Stabilized Patient
• Use the entire team
– EMS providers are often the
first sources of information
• Check the goals
• Formulate the care plan
• Share the plan with patient/
family/surrogate
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
31. Subacute Assessment – NEST
N: Are there social Needs that can guide post-ED
disposition and prevent repeat visits?
E: Does the patient have Existential needs that
mandate attention from ED providers?
S: Which Symptoms, physical or psychological,
require treatment during this visit?
T: What should the Therapeutic goals be for this
ED visit or hospitalization?
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
32. Social Needs
• Access to care
• Caregiving
• Closeness vs. personal isolation
• Financial issues
• Consider engaging social
worker colleagues
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
33. Existential Needs
• Distress
• Worry/anxiety
• Dying words occur in
any setting
• Allow expression of
wishes, desires, hopes
• FICA
– Faith or beliefs
– Importance
– Community
– Address
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
34. Symptoms
• Physical symptoms
• Mental symptoms
– Harder to identify
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
35. Therapeutic
• Goals of care
• Health information
• Therapeutic relationship
• Treatment plan
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
36. 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
regards 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…”
37. 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
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
38. ED Interdisciplinary Team
• Prehospital care
• Triage/bedside nurse
• Physician/nurse
practitioner/physician assistant
• Ancillary ED providers
• Chaplains
• Social worker
• Case manager/coordinator
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
39. Challenges
• Time
• Provider discomfort
– Outside areas of expertise
– Limited use of ED team/referrals
• Reimbursement not in line for
time required
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
40. Communicating Serious Illness
• A number of clinical tools exist
to deliver bad news and facilitate
GOC conversations
• SPIKES method 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
– Fine-tuned to the fast-paced
ED environment
– Helps to rapidly assess patient’s
GOC and disposition to hospice
and palliative care
41. The SPIKES Protocol
• SPIKES is an organized approach to
delivering bad news and discussing GOC:
– Setting up the discussion
– Patient perception
– Invitation
– Knowledge
– Explore emotions and empathize
– Strategy and summary
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.
42. 5-Minute GOC Conversation in ED – Minutes 1–2
• 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
43. 5-Minute GOC Conversation in ED – Minutes 3–4
• 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
44. 5-Minute GOC Conversation in ED – Minute 5
• Introduce ancillary ED resources
(e.g., hospice, observation,
social work, chaplain)
• Summarize and discuss next steps
45. • 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
46. 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
47. Reinforce Facts About Hospice
– 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
– Myth: Care does NOT stop
completely with hospice. Some
palliative treatments can continue
to provide comfort and pain relief
• Introducing hospice to patients and families is a challenge
• There are many patient and provider misunderstandings about
hospice services:
• Overcoming these barriers requires communication with
care and empathy
48. 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?”
49. 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
50. 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
51. 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
53. 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
54. 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•
55. 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
56. 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 enrolled
in 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
57. How VITAS Can Help
Services VITAS Home Health
Nurse 24 hours 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
58. 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 ones1
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/
59. 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
60. 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.
61. 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