Making the Rounds

Recognizing advanced heart failure: How hospice supports better outcomes for patients and care teams

Tue, 31 Mar 2026 04:00:00 -0400

By Heather Veeder, MD, Regional Medical Director, VITAS Healthcare

Heart failure is one of the most common and clinically complex serious illnesses in the United States. Even with advances in medical therapy, many patients experience escalating symptoms, declining function and repeated hospitalizations as they move into the advanced stages of the disease. These challenges place significant strain on clinicians, patients and caregivers.

As a hospice physician, I frequently see patients referred late in the course of heart failure, often during the final days of life. Earlier recognition of advanced decline and earlier hospice involvement can make a meaningful difference. It can stabilize symptoms, reduce avoidable utilization and improve the patient and family experience.

This article summarizes key insights from our recent VITAS Healthcare webinar, Matters of the Heart: Beyond Survival in Advanced Cardiac and Hospice Care, and offers practical guidance for clinicians who care for patients with progressive heart failure.

Patients with heart failure are underrepresented in hospice

Despite the prevalence of heart failure, hospice utilization for these patients remains significantly lower than for those with cancer and other advanced illnesses. The pattern is well known. Patients cycle through the hospital with more frequent exacerbations, appear stable for short periods and then decline quickly.

Several factors contribute to late or no referrals:

Difficulty predicting prognosis
Misconceptions about hospice eligibility
Misconceptions about the need to discontinue disease-modifying therapies
Lack of clarity about how hospice manages complex cardiac needs
The false belief that patients must be DNR to receive hospice care

When hospice is added earlier, patients gain access to patient-centered interdisciplinary support that aligns with their goals while reducing the burden on families and the healthcare system.

Common cardiac diagnoses seen in hospice

Although heart failure takes many forms, the most common diagnoses seen in hospice include:

Heart failure with preserved ejection fraction
Heart failure with reduced ejection fraction
Cardiomyopathy
Atrial fibrillation with rapid ventricular response
Hypertensive heart disease

Most patients present with multiple comorbidities such as COPD, hypertension, chronic kidney disease and cognitive impairment. These conditions complicate management and often accelerate the transition into the advanced stages of heart failure.

Recognizing clinical indicators of hospice eligibility

Heart failure symptoms can be subtle and easy to minimize. Early recognition of these signs can help clinicians identify patients who may benefit from hospice before crisis moments occur.

Key indicators include:

Dyspnea with minimal exertion or at rest
Profound fatigue that limits basic daily activities
Recurrent hospitalizations or emergency visits
Hypotension or intolerance to guideline-directed medical therapy
Weight loss, muscle wasting or declining appetite
Increasing dependence on caregivers
Frequent fluid retention requiring IV or high-dose diuretics
Anxiety or distress caused by breathlessness

These patterns reflect the transition into advanced heart failure, when the goals of care often shift toward comfort, stability and quality of life.

How hospice supports heart failure patients and care teams

Hospice provides a level of home-based support that can be difficult to deliver in traditional outpatient settings. At VITAS, our cardiac trained teams assist patients and partners by:

Managing complex symptoms such as dyspnea, fatigue and anxiety
Providing subcutaneous or IV diuretics when indicated
Supporting oxygen use and other respiratory therapies
Monitoring symptoms during periods of instability
Offering 24/7 clinical access to prevent avoidable hospitalizations
Collaborating closely with cardiologists and heart failure teams
Educating caregivers on what to expect and how to respond to changes

This approach helps stabilize patients in their preferred care setting and reduces the uncertainty clinicians often face when deciding whether a patient is ready for hospice.

AHA Certification

The value of AHA Heart Failure Certification

VITAS has earned the American Heart Association (AHA) Palliative/Hospice Heart Failure Certification across all 15 states in which it operates. VITAS extends AHA-certified, guideline-directed medical therapy across the care continuum, addressing the clinical, emotional and psychosocial needs of patients with advanced cardiac disease and their families.

This certification reflects our commitment to clinical excellence and ensures that our teams:

Receive structured, ongoing heart failure training
Align care plans with AHA best practices
Support patient and caregiver education
Maintain strong care coordination across settings
Offer rapid, consistent access to clinical support

For referring clinicians, this certification provides confidence that their patients are receiving high-quality, cardiac focused end of life care.

Partnering for better patient experiences

Clinicians do not have to manage advanced heart failure alone. Hospice can be an extension of your care, helping patients remain comfortable and reducing the emotional and physical strain on caregivers.

Referring earlier helps patients more, supports families more and gives clinicians the assurance that their patients are receiving the right care at the right time.

Bridging the gap in advanced heart failure care

Mon, 23 Feb 2026 05:00:00 -0500

By Joseph Shega, MD, Chief Medical Officer - VITAS Healthcare

Only one in 10 patients with advanced heart failure is referred to hospice¹, despite evidence that hospice involvement is associated with fewer emergency department visits and hospitalizations and improved quality of life.

At VITAS Healthcare, we want to bridge the gap to ensure patients and families receive the support they need at the end of life.

Our comprehensive cardiac program is certified nationwide by the American Heart Association (AHA), tailored to meet the needs of patients with advanced heart disease, including heart failure and other serious cardiac conditions. The AHA Palliative/Hospice Heart Failure certification recognizes that our clinical practices meet the AHA’s rigorous, evidence-based standards.

5 ways our AHA-certified program enhances quality of life

Below are five ways our AHA‑certified program improves care and comfort for patients with advanced heart disease.

1. Open formulary for cardiac medications

Our open formulary ensures uninterrupted, guideline-directed therapy by access to diuretics, ACE inhibitors, ARBs, beta blockers, nitrates, vasodilators, SGLT2 inhibitors, IV inotropes and other evidence-based cardiac medications.

2. Implantable device support

Patients nearing the end of life often still rely on cardiac devices, such as ICDs, CRTs and LVADs. Our expertise in supporting these devices, aligned with AHA post-implant care standards, enhances hospital quality metrics and improves the patient and family experience.

3. Symptom management

Advanced heart failure brings frequent exacerbations and a heavy symptom load. We continue AHA-recommended therapies and interventions to ease common symptoms like breathlessness, edema, fatigue and pain. Nurses with cardiac expertise are trained to assess and monitor cardiac symptoms, manage medication and intervene early when symptoms intensify.

4. Interdisciplinary support

Our interdisciplinary team delivers individualized care plans with integrated emotional, psychosocial and SDOH-informed support. We coordinate with the patient’s cardiologist for seamless communication on treatment goals, medication changes and device management decisions.

5. 24/7/365 availability for admissions and clinical support

We are available around the clock to give patients, families and healthcare professionals peace of mind and mitigate 911 calls, emergency room visits and rehospitalizations. Our availability also supports hospitals with rapid transitions and immediate care for patients nearing the end of life.

When to refer

Consider a referral to VITAS when patients with advanced heart failure (NYHA Class III or IV):

Have worsening symptoms despite optimal medical therapy (e.g., ACE inhibitors, beta blockers, diuretics, SGLT2 inhibitors)
Experience dyspnea, fatigue or chest pain at rest or with minimal exertion
Have frequent ED visits or hospitalizations

¹Gotsman, I., et al. “Heart failure and preserved left ventricular function: Long‑term clinical outcome.” PLoS One, 2012; CMS Hospice Monitoring Report FY 2025.

Post-Acute Care Options After Surviving Sepsis

Tue, 26 Aug 2025 04:00:00 -0400

By Lauren Loftis, MD, Regional Medical Director

Sepsis is a highly complex medical condition that is a leading cause of death during hospitalization in the United States. Patients who survive sepsis are at very high risk for significant functional impairment, rehospitalization, and death. Patients with medical comorbidities and advanced illnesses such as chronic obstructive pulmonary disease (COPD), heart failure, or cancer before the development of sepsis have an even higher risk of death from sepsis or within six months of discharge.

Healthcare professionals are experts in delivering timely and evidence-based high-intensity interventions to treat sepsis from the moment a sepsis alert is identified. We also have a privileged opportunity and professional responsibility to help patients and their loved ones understand the clinical trajectory of sepsis and likely outcomes.

Having honest and open conversations early, frequently, and transparently can provide a sense of control and autonomy during a critical and stressful time.

Hospice can:

fill the gap and provide timely and ongoing support for patients and families as they travel their sepsis journey
provide a balance between supportive clinical interventions that maximize quality of life, while recognizing that the quantity of life may be shortened
reduce rehospitalizations and in-hospital mortality

Hospice can also provide meaningful and lasting impacts for patients’ caregivers, who report that their wishes were respected, symptoms better controlled, and who experience reduced levels of depression and complicated grief after the death of a loved one.

A Post-Sepsis Case Study

Patients with medical comorbidities and advanced illnesses before the development of sepsis have an even higher risk of death from sepsis or within six months of discharge.

MJ* is a 66-year-old retired elementary school teacher who has advanced COPD. She lives at home with her husband of 45 years, and has three grown children and many grandchildren.

She has had conversations with her family, describing her desire not to be ‘on life support,’ and enjoys participating in her community through her faith and family.

Her COPD has progressed despite maximal medical intervention, and she was recently hospitalized for a COPD exacerbation with community-acquired pneumonia. Her symptoms limit her in 3/6 activities of daily living, and she requires increased assistance at home.

MJ presents to the ED with multiple infected burns after slipping due to weakness while attempting to heat food at home. Upon arrival, she is noted to meet Systemic Inflammatory Response Syndrome (SIRS) criteria, and a rapid sepsis activation is initiated. She receives fluid resuscitation, broad-spectrum antibiotics, and wound care.

48 hours post-admission

Her condition worsened. She developed acute respiratory failure secondary to bilateral pneumonia, acute renal failure, thrombocytopenia, and hyperlactatemia. Mechanical ventilation, hemodialysis, and vasopressors were initiated.

10 days post-admission

She was weaned off the ventilator. Kidney function and labs improved, vital signs stabilized, but functional decline continued. She experienced a 20-lb weight loss and mild delirium. Now dependent in 4/6 activities of daily living, she was discharged to home health for physical therapy.

14 days post-admission

MJ’s condition continued to deteriorate. She did not tolerate physical therapy and developed progressive respiratory congestion and shortness of breath. Her primary care physician diagnosed aspiration pneumonia and recognized that MJ did not want to return to the hospital. A goals-of-care conversation revealed her request for comfort care to allow her to receive treatment at home, so she was referred to hospice and admitted the same day.

The Value of Hospice Post-Sepsis

Every patient is a unique human being with individual needs, but the systemic inflammation and life-threatening organ dysfunction associated with sepsis result in a challenging prognosis with very high mortality and morbidity. Hospice was a viable option for MJ both at the time of her critical care episode of sepsis, based on pre-hospital hospice eligibility guidelines, and increased sepsis-related clinical complications.

Appropriate hospice utilization can break the cycle of readmission and present an alternative to prolonged or invasive acute care interventions:

Once referred to hospice, MJ received coordinated and comprehensive care at home from an interdisciplinary team, including a hospice physician, nurse, home health aide, social worker, chaplain, volunteer, respiratory therapist, and physical therapist.
In two instances, symptom exacerbation required continuous care, which, in the absence of hospice, would require hospitalization. Instead, she received around-the-clock Intensive Comfort Care at home, honoring her wishes to remain home.
Her care plan and the frequency of visits were adjusted in real-time to ensure her needs were met.
She received complex modalities for high-acuity symptoms, all medications from our open formulary, and delivery of medical equipment and supplies, all part of the Medicare Hospice Benefit.

MJ died peacefully, surrounded by family, four months after discharge from the hospital. Her husband and family received bereavement support for 13 months after her death. They report that MJ’s wishes were honored, and while they grieve the loss of the family matriarch, they are grateful that they were able to spend her last chapter by her side in the family home.

Initiating Goals of Care Early and Often

Even while focused on goal-directed therapy and rapid response protocols, it’s highly beneficial to incorporate goals of care conversations and embed palliative considerations within algorithms to ensure that the care delivered is consistent with each patient’s personal goals of care. The clinical course of sepsis often unfolds rapidly within critical care environments, and it can be easy to forget that each patient is a unique human being with individual values that should be taken into consideration to ensure they are honored.

By initiating goals-of-care conversations earlier, it empowers patients and their families to make informed decisions and refocus care on improving quality of life and managing symptoms.

The ideal time to refer a patient to hospice is as soon as they are eligible. In the case of MJ, ideally, a goals of care conversation might have occurred during her hospitalization for COPD exacerbation/pneumonia, even before the development of sepsis. During her episode of sepsis, early and ongoing conversations enabled her husband and family to make key decisions to help ensure that her wishes were honored and that her care team was able to deliver person-oriented support even in the face of critical illness.

*The patient case study referenced here is a fictionalized account created for illustrative purposes. While the details reflect a typical hospice patient experience and are rooted in clinical reality, the patient initials and certain identifying information have been altered to protect privacy and ensure anonymity.

Expert Insights: Cultural Considerations in Hospice Goals-of-Care Conversations

Mon, 08 Sep 2025 04:00:00 -0400

To deliver culturally sensitive care, healthcare professionals must keep an open mind and adopt a broad view of culture that extends beyond race and ethnicity. Respecting cultural diversity and individuality helps build trust, improve communication, and ensure that care aligns with a patient’s wishes.

Inpatient Hospice Versus Comfort Measures Only in a Hospital Setting

Mon, 09 Jun 2025 04:00:00 -0400

By Joseph Shega, MD, Executive Vice President and Chief Medical Officer, VITAS Healthcare

When a hospitalized patient's condition reaches a point where curative treatment no longer offers benefits and the patient is actively dying, healthcare professionals are faced with a decision. Should you recommend general inpatient (GIP) hospice care Comfort Measures Only (CMO)?

Though both approaches prioritize comfort over non-beneficial curative care, understanding the differences is crucial to help inform the best choice for your patient and their family.

Understanding the Difference Between Comfort Measures Only and General Inpatient Hospice Care

Comfort Measures Only

CMO ceases curative treatment and focuses exclusively on relieving discomfort, pain, and distress for patients nearing the end of life. It is often implemented during a hospital stay with appropriate medications and bedside care.

However, CMO is not a full care program and does not include the additional layers of support that the majority of patients and families need during the end-of-life transition.

General Inpatient Hospice Care

GIP is a structured, comprehensive program designed to enhance the quality of life for dying patients. It addresses physical, emotional, and spiritual needs through a team-based approach. If a GIP patient is discharged from the hospital, hospice care can continue in multiple settings, including assisted living facilities, nursing homes, and private residences.

Hospice support extends to the patient’s family no matter where the care is provided.

The critical distinction between CMO and GIP is the latter’s ability to provide more than just medications for patients to try and alleviate symptoms. GIP delivers a full continuum of support services to ensure both patients and their families feel seen, heard, and supported throughout this universal experience.

Benefits of General Inpatient Hospice Care

Referring a patient to GIP offers distinct advantages that go far beyond what CMO can provide.

Expertise in Pain and Symptom Management

GIP includes physicians board certified in hospice and palliative medicine, and comprehensive care teams highly skilled in addressing complex symptoms such as pain, agitation/restlessness, and respiratory distress. Every treatment plan is individualized, ensuring optimal comfort for patients.

Holistic, Patient-Centered Approach

GIP addresses the whole person, incorporating physical, emotional, and spiritual elements in line with the patient’s care goals. Social workers and chaplains provide added guidance, helping patients and families cope with feelings of grief, confusion, and loss.

Support for Families

Unlike CMO, GIP support extends to the family. The hospice care team helps educate families so they can prepare for the physical and emotional changes that the patient may experience, including clinical signs of dying. They help families navigate anticipatory grief and provide bereavement support and resources for up to 13 months after a patient has passed away. The hospice care team can also support post-death arrangements, including facilitation and completion of the death certificate.

Accessible, Around-the-Clock Care

Hospice care guarantees 24/7/365 availability of board-certified physicians, hospice nurse specialists, chaplains, and social workers. Whether it is a medical crisis or the family needs psychosocial support, the care team is available whenever they are needed.

Beyond Comfort Measures

While Comfort Measures Only care can try to address immediate patient needs within the hospital setting, hospice care offers a more comprehensive, compassionate, and specialized approach that extends far beyond the hospital's walls. From evidence-based protocols in pain and symptom management to emotional and spiritual support, hospice care ensures that patients and families receive meaningful, dignified care during life’s most vulnerable moments.

By understanding the benefits of hospice and recognizing when it is appropriate to make a referral, healthcare professionals can profoundly impact their patients’ experiences and outcomes.

Take the Next Step

If you’re considering hospice services for your patients, choose a trusted partner like VITAS Healthcare. As a pioneer and national leader, VITAS offers unparalleled support to patients, families, and the medical community. Learn more or make a referral today.

The Many Gifts of Hospice: What Patients Can Receive Rather Than ‘Giving Up’

Mon, 25 Nov 2024 05:00:00 -0500

Regional Medical Directors Dr. Lauren Loftis and Dr. Sandhya Bhalla-Regev, Medical Director Dr. Ajit Hansalia, and National Director of Sales Training Maite Hernandez, RN, joined Executive Vice President and Chief Medical Officer Dr. Joseph Shega on November 6, 2024, for a panel discussing the hospice journey. Here is a summary of their presentation.

Hospice is commonly thought of as an option that is essentially ‘giving up.’ Yet once patients have exhausted avenues for curative care, hospice becomes a choice for increasing their quality of life instead. Patients receive 24/7 clinical support that helps manage pain and symptoms along with a full team of experts to provide interdisciplinary support. Hospice care allows seriously ill patients and their families to focus on what is most important to them in their final months, weeks, and days.

In 1982, the federal government established the Medicare Hospice Benefit for patients who have a prognosis of six months or less to live if their disease state runs its normal course. Common diagnoses for those with advanced illness who may qualify for hospice include cancer, Alzheimer’s/dementia and other neurological diseases, advanced cardiac disease, advanced lung disease, as well as other, less common conditions including ALS, sepsis, liver or renal disease, and HIV/AIDS.

One Physician’s Journey to Hospice With His Father: Seeing the Value in Real Time

As Dr. Joseph Shega relays, caring for his father with advanced cancer helped him see hospice through a more personal lens.

“After 11 years of anti-tumor treatment for stage 4 colorectal cancer, my dad had a myocardial infarction that further weakened him and led us to a goals-of-care conversation,” says Dr. Shega. “The anti-tumor treatments caused him to feel more and more fatigued. After additional hospitalizations for recurrent infections, he could no longer muster the energy or will to get to his baseline functional status. I asked him how he wanted to live during his remaining time.”

William Shega wanted to spend time at home, not pursuing acute care that would not likely prolong his life and only increase his suffering. He knew he was not getting stronger. Because hospice is the only post-acute setting that can titrate to the level of care needed without changing the care setting, Mr. Shega could remain at home surrounded by his wife and loved ones. Hospice services provided goal-directed palliative care, improved pain control, and increased Mr. Shega’s satisfaction.

With a team of experts to assist family caregivers in the day-to-day management of his symptoms, home medical equipment, and medications, and home health aides to help with activities of daily living, Mr. Shega received the care he was seeking in the comfort of his home.

Should he have needed a higher level of care, Mr. Shega had access to Intensive Comfort Care®, which enables continuous care for acute symptom management or inpatient care at a dedicated hospice inpatient facility if his symptoms became more than could be managed at home.

Also, if family caregivers are at risk of burnout, short-term respite care in a Medicare-certified hospital, hospice facility, or long-term care facility for up to five days is available.

With multiple levels of care and medical, psychosocial, and spiritual support, hospice offered the services that helped Mr. Shega spend time with his grandchildren and children.

“Hospice is a beautiful gift, giving autonomy and control back to the patient,” says Dr. Shega.

Treat Patients as You Would Family Members: Ask About Goals of Care

Without a goals-of-care conversation, physicians do not know what the patient prefers for their end-of-life journey and patients do not know all of their care options. Initiating these conversations allows patients and families to engage in advance care planning. Two approaches provide a framework for healthcare professionals to pursue this conversation:

SPIKES is a mnemonic that incorporates an approach for the conversation and refers to Setting, Perception, Invitation, Knowledge, Emotion, and Summarize. Learn more about it here.
ACACT helps clinicians work through common objections when talking about end-of-life care: acknowledge the difficult decision, clarify their concerns, answer questions, confirm the decision to choose hospice, transition to practical next steps.

Healthcare professionals can respond with clarity and accuracy and become more comfortable and skilled at addressing individual needs once they are prepared for common objections. Each of these approaches helps the clinician interact with patients and families empathetically.

Choosing a Better Ending

Hospice is not about death and dying. Mr. Shega’s story is one shared by countless families across the country. Patients with advanced cancer often reach a point where curative therapies become “palliative” therapies—medicine can’t cure the disease, but hospice can maximize their quality of life for as long as possible.

Often discontinuation of cytotoxic chemotherapies can actually reduce morbidity and help patients experience a better quality of life. By identifying hospice-eligible patients earlier, they receive the full breadth of services they are entitled to as their serious illness continues to progress.

One of the most important aspects of the Medicare Hospice Benefit is that hospice provides dedicated family and caregiver support and ongoing bereavement services prior to and after death for at least 13 months. Without hospice, most families go without these services and face loss alone.

To refer your hospice-eligible patient to VITAS, contact us at 800-582-9533.

Compassionate Pain Management

Wed, 23 Oct 2024 04:00:00 -0400

By Dr. Lauren Loftis, Regional Medical Director, VITAS Healthcare

Pain and discomfort can be under-recognized and under-treated in patients with serious illness. At the end of life, 81% of patients cite being pain free as an important factor in dying a “good death.” ¹ Along with the physiological pain associated with a patient’s terminal illness, anxiety and depression may contribute to their “total pain.” Social, emotional, and spiritual dimensions of total pain increase the patient’s suffering beyond their physical discomfort.

A holistic approach to targeting pain at the end of life enables physicians to provide relief and comfort care that improve the patient’s quality of life.

To illustrate, a patient I’ll call Bob Jones is a 65-year-old male with stage IV colon cancer and extensive metastases to the bone, liver, and brain. Mr. Jones’ wife is his caretaker, and he is estranged from his son who lives out of state. His son does not accept his terminal diagnosis. Despite surgery, chemotherapy, and radiation, Mr. Jones’ disease has progressed.

As I meet Mr. Jones for an initial hospice encounter, I ask open-ended questions, especially what matters most to him at this point in his disease progression, to determine his goals of care. I learn he is a Vietnam Veteran with signs of undiagnosed PTSD. He is constipated and desires to return home and spend time with his wife. He wishes to go to Hawaii but fears that this can no longer happen. His son does not want him to take morphine.

Looking at the “Total” Picture: Optimizing Patient Comfort

As physicians, when we ask about pain, we keep in mind that it is defined by the patient. Hospice clinicians manage pain based on the needs and expectations of the patient and family, not our own.

Getting an accurate measure of the pain level is necessary for appropriate treatment. The patient may be reluctant to report pain for fear of being a “complainer” or a desire to avoid opioids. Asking open-ended questions may help you gauge pain more effectively:

How severe is the pain?
Where is the pain located?
What are you taking for the pain? How is that working for you?
How is the pain affecting your ability to function daily, such as bathing, dressing, and the ability to get up and walk?
Is the pain impacting your ability to fall or stay asleep?
How is the pain impacting your mood?
Is the pain impacting your ability to socialize or spend time with the ones you love?

Other indicators of pain and suffering can be viewed or discussed. Dryness of the eyes can lead to painful keratitis as well as infections. Patients on long-term oxygen therapy may have skin breaks around the nares, dryness, and episodes of epistaxis, which can be distressing. Patients who have been using noninvasive modes of ventilation may have pressure ulcers at the nasal bridge and cheeks. Pooling oral secretions and lack of oral care can lead to oral ulcers and dental issues.

Signs of malnutrition include temporal wasting, supra, infra-clavicular wasting, scaphoid abdomen, and skin dryness. Loss of muscle mass can create an increased risk of skin breakdown. Dehydration signs include dryness of mucosal surfaces, loss of skin turgor, and dry skin. Abdominal fullness can point towards constipation or urinary retention, which can cause significant distress to the patient. Lastly, a hygiene assessment and well-being focused on maintaining the patient's dignity are essential.

For Mr. Jones, our VITAS team contacted his son to discuss his hesitation to provide pain medication for his father. Using a calm and thoughtful approach, we explored where his beliefs came from and if they were simply based on a common misconception about the use of morphine in hospice patients.

Mr. Jones had agreed to hospice services “to get out of this place,” meaning the hospital, and go home to sleep in his own bed, with his wife and dogs nearby, his stated goals for end of life. He received Continuous Care to help manage his symptoms at home. The VITAS hospice physician evaluated him at admission and after transport to his home. Clinicians profiled his medications, which we arranged to be delivered to the home along with a bedside commode, walker, oxygen, and briefs.

Managing Both Physical and Nonphysical Pain

Once in hospice, the interdisciplinary team—a team manager, primary nurse, hospice aide, physician, chaplain, social worker, team physician, and volunteer—collaborates to address the patient’s total pain beyond opioids alone. VITAS also has an in-house pharmacy team with Pharm Ds on call to assist with symptom management consultations, medication selection, and dose conversions.

After Mr. Jones arrived home, the home health aide gave Mr. Jones the first true bath he had had in weeks. The team addressed his constipation. We consulted our VITAS social worker and chaplain to help him and his family. The VITAS Pharm D assisted with a methadone titration regimen and pharmacologic selection.

With these interventions, Mr. Jones “felt so much better he couldn’t believe it” and “wished he’d called us months ago.” He was able to live at home for nearly six months after his hospitalization. His course of symptom management allowed him to make meaningful memories with his family. He also achieved resolution to his estrangement with his son, which was not only significant to him but also the rest of the family, even beyond Mr. Jones’ death.

Focusing on Quality of Life With Compassionate Care

A total pain approach to comfort care minimizes any medication side effects—even those not related to the terminal illness—while enhancing the patient’s:

Functional ability
Physical well-being
Psychological well-being
Spiritual well-being

This includes empowering the patient to participate in decision-making, which helps them retain dignity and a sense of control.

The emphasis of comfort care is to improve the patient’s quality of life in their remaining months, weeks, and days. The outcomes of the hospice interdisciplinary care team’s efforts are evident—in the photos we receive and the kind words of family members and even patients themselves who entrusted their care to us. Like Mr. Jones, many tell us: “We wish we knew about hospice sooner.”

Questions about total pain management? Ready to refer a patient? Contact your VITAS representative.

¹Meier, Emily, et al. (2016). “Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue.” American Journal of Geriatric Psychiatry. Retrieved Sept. 16, 2024

Disparities in Minority and CMO Patients

Wed, 09 Oct 2024 04:00:00 -0400

By Dr. Joseph Shega, Chief Medical Officer, VITAS Healthcare

Hospice provides myriad benefits to patients nearing the end of life: improved quality of life, better symptom and pain control, and greater patient and family satisfaction. However, despite increases year over year in the number of beneficiaries who used the Medicare Hospice Benefit, hospice remains underutilized in some patient populations. Two such populations present an opportunity for improvement: inpatients placed on Comfort Measures Only (CMO) and patients of color. Both groups face unique barriers to accessing hospice care.

The Need for General Inpatient Hospice (GIP) Among Comfort Measures Only (CMO) Patients

Most hospice care (more than 98%) occurs in the home, whether a private residence, assisted living community, or nursing home. However, when a hospice patient’s symptoms can no longer be managed at home, they may move to a General Inpatient Care (GIP) setting for a short period of time to manage acute symptoms and pain. Despite being one of the four levels of hospice care required by Medicare-certified hospice organizations, GIP care remains uncommon. According to National Hospice and Palliative Care Organization (NHPCO) data, in fiscal year 2022, GIP comprised only 0.88% of Medicare days of care.¹

This need for an enhanced level of care is particularly evident when examining hospitalized patients on Comfort Measures Only (CMO), or comfort care—a population that may widely benefit from being admitted to GIP care to manage their pain and other symptoms before returning home to receive routine hospice care.

A 2023 retrospective cohort study by Kozhevnikov et al. showed that around 22% of studied patients who transitioned to CMO status during their terminal hospital admission received general inpatient hospice care before death.² CMO decedents who died without GIP during their terminal hospitalization were more likely to die in an ICU, have a lower Rothman Index (i.e., a higher risk of adverse events, clinical deterioration, and worse outcomes), and spend less time with CMO status.² Further, without hospice care, families do not receive the 13 months of bereavement support that hospice provides after the patient’s death.

Improving access to GIP hospice care among patients on CMO and awareness among care team members will result in more patients being able to benefit from the specialty symptom management, treatment of psychological and spiritual distress, and bereavement support that hospice can provide.

Underutilization in Minority Groups

Along with the barriers faced by CMO patients, racial disparities play a significant role in the underutilization of both palliative and hospice care, particularly among minority groups.

A 2024 study by Cid et al. found that minority patients were less likely than White patients to have documented end-of-life care during terminal hospitalizations.³ Using palliative care encounters and do-not-resuscitate (DNR) status as metrics for end-of-life care, the study showed that, compared to White patients, Black patients were 17% less likely to have palliative care encounters and 9% less likely to have DNR status.¹

Going beyond this study's metrics, racial disparity can also be seen in hospice utilization. The NHPCO found that among Medicare decedents in 2022, hospice use occurred in 51.6% of White Medicare decedent beneficiaries, but among only 38.3% of Hispanic decedents, 38.1% of Asian-American decedents, 37.4% of Black decedents, and 37.1% of North American Native decedents.¹

Improving these metrics may begin with goals-of-care conversations. Initiated by clinicians, these conversations help uncover a patient’s wishes, values, and care preferences. From these discussions, we can help inform patients and their families about their options for end-of-life care, including hospice.

It is our duty as clinicians to have these conversations early and often with our seriously ill patients and their families, so they are well-informed of the care choices available as their disease continues to progress. Healthcare professionals should ask open-ended questions to understand what matters most to patients facing serious illness.

For minority groups, approaching these conversations in a culturally sensitive and respectful manner is paramount. This may include considering language preferences, understanding specific cultural or religious beliefs around illness and death, and involving family members in the decision-making process.

An Opportunity for Change and Improvement

Over the years, hospice awareness and utilization have grown, but it remains underutilized among terminally hospitalized patients on CMO and patients of color. These two unique populations present their own challenges and opportunities regarding access to hospice, highlighting the need for effective goals-of-care conversations to increase hospice awareness and accessibility.

By fostering culturally sensitive conversations that increase awareness of the Medicare Hospice Benefit, we ensure that patients and families from all backgrounds have the option to receive the compassionate, equitable end-of-life care they deserve. These efforts will help bridge disparities and improve the quality of care for countless individuals and their families.

1. National Hospice and Palliative Care Organization. NHPCO Facts and Figures. 2024. Available from: https://www.nhpco.org/hospice-facts-figures [Last accessed: September 11, 2024].
2. Kozhevnikov D, et al. Factors associated with inpatient hospice utilization among hospitalized decedents with comfort measures only status. Journal of Palliative Medicine. 2023;26(8):1048-1055. doi:10.1089/jpm.2022.0460
3. Cid M, et al. Disparities in end‐of‐life care for minoritized racial and ethnic patients during terminal hospitalizations in New York State. Journal of the American Geriatrics Society. Published online July 10, 2024. doi:10.1111/jgs.19046

Strengthening Our Sensitivity When Caring for Older Adults

Tue, 01 Oct 2024 04:00:00 -0400

By Dr. Valerie Hart Quezada, Team Physician/Geriatrician, VITAS Healthcare

If we believe in stereotypes, older adults are all the same. Yet this fast-growing population is very complex and diverse. They defy a simple description because chronological age is not the same as physiologic age.

Both Sylvester Stallone and Arnold Schwarzenegger are in their late seventies while living robust, active and independent lives. Contrast this with a frail individual of the same age living in a nursing home with balance and mobility issues who relies on support for daily living activities.

Approaching the Older Patient

Because we age in different ways, it’s important to know as much as possible about the patient we are treating and cultivate skills to match care to their health, functional status, priorities, and life expectancy. It is not enough to know age and comorbidities only.

The baby boomer population is living longer yet doing so with chronic illnesses. Often, health professionals are not well prepared to care for patients with multiple chronic conditions and have a harder time understanding disease trajectories. The “silver tsunami” of 73 million individuals in the US will require the mindfulness and holistic care of clinicians.

Physiologic vs. Chronological Age

The normal aging process produces an increase in hearing and vision issues, frailty, sleep disturbances, urinary tract infections (UTIs), potential falls, gait and balance issues, and osteoporosis.

How the body manages these changes will depend more on physiologic age than chronological age.

Chronological age is the number of years, months, days since birth.
Physiologic age is the patient’s functional age based on their lifestyle, diet, exercise or fitness level, and even education.

When aging, cellular and molecular damage contribute to a decrease in physiologic reserve, or the body’s ability to withstand stress and recover from illness. The loss of muscle mass, increase in cortisol, and changes in hormones and blood pressure can affect homeostasis. With decreased physiologic reserve, small “insults” can result in significant decline. A new medication can lead to acute renal failure. Contracting pneumonia can turn into respiratory failure. A minor illness or even dehydration can produce delirium.

Suppose an 85-year-old who is robust, independent, and perhaps still driving gets a UTI. They may experience a dip in functionality but can likely recover quickly. Another 85-year-old who is weaker and frail may also acquire a UTI—and may not be able to recover to baseline.

Applying the 4M’s to Determine Health Status and Goals

Developed by the Institute for Healthcare Improvement, the “4M’s” help healthcare professionals gauge the status of their patients. They are:

Mentation, which is the patient’s presentation of dementia, delirium, or depression. What is their mental state? Do they have cognitive challenges or are their typical age-related responses?
Mobility or their ability to get around. Do they use a cane or rollator? Do they need to? Older adults value being independent, so we need to identify when they start to become frailer and find ways to address barriers to being more active.
Medications: Review these and identify what does not belong and discontinue. Ensure they understand the medications they are taking. Also, can they manage their medications?
What matters most? Asking this question will help you identify what their values and goals are. These may vary by cultural or religious affiliation, life experiences and diseases. Do they want to be more active? Spend more time with family? What will help them achieve what matters most to them?

A fifth “M” can be multimorbidity if the patient is experiencing several chronic conditions.

Open-Ended Questions: What HCPs Can Ask

Remember that most older adults do not want to become a burden to loved ones. When they express this to us, it is a good place to start the conversation. This is an ongoing discussion because it can change for the patient over time, as their serious illness progresses. Here is a sampling of questions:

What do you think is going on with your health? This enables physicians to prognosticate.
What do you think the healthcare system or I can do for you? Identifies the patient’s expectations.
Is there something you want to do in the future? Or, what activities do you find enjoyable that may have been disrupted? Physical therapy may help them increase their abilities.
Who is important in your life? How often do you see them? This can reveal social deficits and isolation.
Are you able to care for yourself? They may not reveal deficiencies unless asked. Minor interventions can help.

Once assessed, acting on these responses can help us align the care plan with what matters most to the older adult. If opting for hospice and palliative care, the patient receives wholistic care that includes medical, psychosocial, and spiritual support. Sharing information about the Medicare Hospice Benefit, which covers 100% of hospice services under Medicare Part A, can ease the patient’s mind about financing this type of end-of-life care.

Respect: The Key to Sensitivity

Older adults are experts on aging, and it helps to show them sincerity and empathy. Because they sometimes experience ageism from their community, the healthcare system, or even their own family, they may not receive the care they need.

Breakdowns in care may happen when healthcare professionals assume all older adults are the same or focus only on the “medical” instead of the whole person. The cognitive/emotional, familial/social, environmental, and financial domains are interconnected. Taking this whole-hearted approach will help healthcare professionals provide care that enhances their quality of life.

Do you have a patient with serious illness or multiple morbidities? Could it be time to have a goals of care conversation? For assistance with this conversation or questions about hospice-eligibility, contact VITAS.

Higher Levels of Care at Inpatient Units

Wed, 25 Sep 2024 04:00:00 -0400

What happens when a hospice patient has a medical crisis or experiences symptoms that cannot be managed at home? Rather than returning to the ED, VITAS offers another option: symptom optimization at an inpatient unit (IPU). IPUs offer a higher level of care in a comforting, onsite environment.

Under the Medicare Hospice Benefit, all hospices must offer GIP (general inpatient) level of care to assess and manage acute, complex, or uncontrolled symptoms such as pain or shortness of breath, with IPUs being one example of a GIP care setting. However, the delivery of this care may vary by provider.

VITAS RN cares for a hospice patient in an inpatient unit (IPU).

VITAS IPUs and suites are staffed by a VITAS care team, including a physician who makes daily rounds and nurses who provide 24/7 care. Integrated team members such as social workers, chaplains, music therapists, and Paw Pals^®pet visits provide psychological and social support as needed*. Typically, many VITAS IPUs have accommodations for family members to stay so they are near their loved one.

Four Levels of Care

General inpatient hospice (GIP) care is one of four levels of care VITAS offers under the Medicare Hospice Benefit. When a VITAS physician determines that a hospice patient is eligible for GIP level of care,** VITAS collaborates with the hospital or facility staff to coordinate a comfort-focused plan of care.

Other levels of care (LOC) include:

Routine Home Care in the patient’s residence (private home or senior living community) with scheduled, routine visits by care team members, including hospice physician, registered nurse, aide, social worker, chaplain, volunteer, and bereavement specialist. This is the most common type of hospice care.
Continuous Home Care, which brings shifts of acute symptom management to the patient’s bedside for up to 24 hours/day. VITAS calls this Intensive Comfort Care^®.
Inpatient Respite Care provides a temporary break for primary caregivers who are at risk for burnout. Hospice patients receive 24-hour care in a Medicare-certified hospital, hospice facility, or long-term care facility for up to five days.

Short-term Inpatient Clinical Care*

At an IPU, the patient receives intensive, high-acuity care that may be too challenging to provide in their home environment. If the patient needs frequent dose changes in analgesic or other medication or treatment that require close monitoring, is having new or recurrent seizures, or has wounds that need frequent dressing changes that cannot be done in the home, the patient may benefit from an IPU stay.

While some procedures can be handled by VITAS Intensive Comfort Care^® in the home, others are better suited for an inpatient setting where things are more controlled and other treatments are readily available, such as paracentesis or thoracentesis. If a cancer patient’s hemoglobin drops quickly, they may need a blood transfusion to restore their strength, which may be administered in a hospital-based IPU.*

These are only some examples of clinical care that may mandate an IPU short-term stay. Once admitted, the hospice care team:

Evaluates symptoms
Provides intensive symptom management
Maintains around-the-clock care and regular visits

Similar to other levels of care, Medicare payments for inpatient care include all services, medications, equipment, and supplies related to the terminal illness. When care unrelated to a patient’s advanced illness is necessary, Medicare Parts A and B may cover expenses under normal rules.

Home-Like Environment Focuses on Comfort

VITAS units offer amenities like family rooms, kitchens, and children’s play areas. We include places for quiet contemplation or prayer and spaces that accommodate the needs of multiple generations. A cup of coffee and facilities to reheat a home-cooked meal are always available.

Like the physical surroundings, the environment is soothing and family oriented. Team members get to know patients and their loved ones and include them in care. They may help out-of-towners navigate the area or welcome the visit of a beloved pet. This enhances quality of life for patients and families even when intensive care is necessary.

Returning Home

The goal of the short-term stay in an IPU is to provide the clinical care and onsite monitoring to stabilize the patient so they can return home. Once the patient’s crisis improves, the interventions or medications that require skilled nursing care may no longer be necessary.

Upon leaving the IPU, the patient’s hospice services will resume in their home or senior living community. They will return to their previous level of care with 24/7/365 clinical support from VITAS, high-acuity care, and full interdisciplinary team services to promote comfort and dignity.

Have a patient with serious illness who may be hospice eligible? Refer to VITAS today.

*May vary by VITAS program and requires clinical case discussion between the VITAS medical director and attending physician. Demonstrates VITAS^®Healthcare care model, not all hospices may provide listed services. In addition to the complex modalities, the following may be incorporated in a patient’s plan of care: Goals-of-care conversations, PT, OT, speech therapy, nutritional counseling and specialized HME.

**Per Medicare guidelines, higher levels of care are provided when a VITAS physician determines a patient is eligible for a higher level of care (LOC) or GIP. Eligibility to remain on a higher LOC is assessed by a VITAS RN and VITAS physician daily. Higher LOCs are provided on a temporary basis until the symptom(s) are optimally managed.

Fulfilling the Hospice Journey: Grief & Bereavement Care With VITAS

Thu, 08 Aug 2024 04:00:00 -0400

As loved ones linger nearby, Lead of National Spiritual Services and Chaplain Jason Cooper sits bedside with hospice patients nearing the end of life. His view of grief is informed by many hours spent listening, comforting, and providing spiritual care, which begins on day one of admission.

“Grief hits people in different ways,” he says. “It may evoke many emotions, and it isn’t linear. People swing between stages. Acceptance at one moment can turn into intense despair or anger the next.”

Grief is also a unique experience for everyone.

Emotional and Behavioral Responses to Grief

The grief experts—a VITAS chaplain and clinical social worker—meet with the patient and family members throughout the hospice journey to respond to their individual needs.

“Together, team members address all aspects of care—clinical, emotional, and spiritual,” says Lead of National Psychosocial Services Jessica McClure, LCSW.

“People often feel profound sadness but sometimes also anger, guilt, and maybe relief, especially if their loved one has been suffering for a long time,” says Jason. “Others say they feel numb with a sense of disbelief that this could happen. Some describe a feeling of emotional disembodiment as if they are watching things happen from a distance.”

Typical behavioral responses can be varied, including:

Withdrawal from friends or family members
Avoiding places that remind them of their loved one
Visiting places with shared memories of their loved one
Delaying sorting through their loved one’s items
Getting rid of all their loved one’s personal items
Feeling they must act a certain way and not show too many sad emotions
Honoring the loved one every chance they get
Avoiding being alone

Some simply cannot talk about their grief. “People can shut down,” says Jason. “We approach this with sensitivity for their emotional state. We never push them to talk before they’re ready. Instead, we create a safe and supportive environment where they feel comfortable.”

These grief experts can also recommend alternative ways for processing emotions, including art therapy, music therapy, journaling, or other activities that don’t require them to talk about it directly.
“We respect their boundaries and timing,” he says. “We’re available whenever they’re ready to talk.”

How VITAS Provides Grief Support Before, During, and After a Death

With VITAS, the same chaplains and social workers who supported the patient during hospice services also provide grief support. “This allows for more rapport with the caregiver and family members,” says Jessica. “While some hospice providers use a separate department of counselors, we find it beneficial for the bereaved to talk with those who knew their loved one and shared in their experience.”

Medicare specifies that hospice providers must offer twelve months of bereavement support. Yet, VITAS provides 13 months. “The one-year anniversary of a loved one’s death is often very difficult,” explains Jason. “The last thing we want to do is discontinue our support on that anniversary. We extend support for another month to ensure the family can navigate that difficult milestone.”

The VITAS grief support process is multi-tiered. “We provide both condolence calls and visits within the first week or so after the patient’s death,” says Jessica. “Subsequent check-in calls and mailings assist family members or caregivers in building a support system. We help them identify who they can call and what resources they have. VITAS remains available if the grief process changes, and they need different support.”

If additional support is necessary, VITAS connects more often: daily up to every two weeks depending on the severity of the grief.

“We consistently assess this frequency,” says Jessica. “Our volunteers check in with primary caregivers two months following a death. At this time, the caregivers’ support system can begin to dwindle as people resume their lives. The initial year after the death brings many ‘firsts,’ so we send mailings throughout that year to highlight feelings that may arise and how to cope. We want them to know they are not alone, and VITAS is here to help.”

Meanwhile, chaplains assist families in navigating issues that loss brings up—questions about faith, life, and death. “We provide spiritual guidance tailored to the beliefs and traditions of the family,” says Jason. “We may assist in creating meaningful rituals or ceremonies to honor the person who has passed, such as a religious service, a moment of reflection, or something personal that helps the family find closure and begin to heal. We don’t in any way seek to convert or proselytize.”

Why Earlier Hospice May Be Better for the Grieving Process

When a patient dies quickly after entering hospice, loved ones may feel unprepared emotionally and struggle with disbelief. “This sudden loss can make it challenging for family to process grief,” says Jason. “The grief can be more intense. They may feel shocked and struggle to comprehend the sudden change in circumstances.”

When a patient receives hospice care longer, loved ones work through anticipatory grief, or grief that occurs before a loss. “A longer length of stay allows them time to gradually come to terms with the impending loss,” says Jason. “The care team will have more time to encourage open discussion between the patient and their loved ones to facilitate a healthy grief process. This is one of many reasons why it is beneficial to have a longer length of stay in hospice so the team can work with families as soon as possible.”

What Healthcare Providers Can Do

Healthcare providers can support grieving loved ones by being present and validating their emotions. A simple condolence expresses thoughtfulness such as, “I am so sorry for your loss,” or “You and your family are in my thoughts as you grieve this loss.” VITAS can arrange to educate your staff on supporting the bereaved and coping with their own grief as well.

“Be mindful of nonverbal language,” suggests Jessica. “Unintentionally, we can seem as if we are rushing by checking the time or standing near the door. Sit with the client. Notice where your body is facing, even your feet.”

Also, understand that grief isn’t just a passing emotion. “It can deeply affect a person’s well-being,” says Jason. “They might struggle with anxiety, depression, or have trouble concentrating. Some may experience physical symptoms such as fatigue, changes in appetite, or physical pain that is unrelated to any medical condition. Acknowledge these emotions without trying to rush them through their grief.”

Other helpful tips for healthcare professionals include:

Remember every person’s grief response is unique—there is no right or wrong way to feel
Actively listen and validate what you hear. For example, if someone says, “I just lost my mom last week, and it’s been really hard,” you might respond with, “I’m sure it’s been incredibly difficult. How are you coping with her loss?”
Avoid comparisons with your personal experiences which can shut them down. Be aware phrases like, “I know how you feel,” or “I’ve been there before,” or even, “When my mom died, I,” tend to marginalize the other person’s emotional experiences.
Recognize that you cannot fix it or make it better. Being present with someone who is grieving can be the most effective intervention

Encountering Complicated Grief

Those early in the grief process may need to isolate or sleep more to process the heavy emotions that come with grief. Yet, prolonged, intense grief can become complicated grief. Debilitating grief symptoms may affect the individuals’ day-to-day life for an extended time and become cause for concern. These include struggling with carrying out typical activities and/or:

Intense sorrow, pain, and rumination over the loss of loved one
Focusing the loved one's death and little else
Intense and persistent longing or pining for the deceased
Problems accepting the death
Numbness or detachment
Expressing feelings that life holds no meaning or purpose and/ or not worth living without loved one
Sharing wanting to have died along with loved one

“Someone who is experiencing complicated grief may have more severe, intense emotional responses and remain in those emotions for a longer time,” says Jessica.

Some risk factors for complicated grief may include:

Sudden or traumatic loss, such as experiencing the death of a child
Lack of sufficient social support
Personal history of mental health struggles
Unresolved grief from previous losses and/or possibly:
- An estranged relationship which was not mended or explored emotionally with the patient before their death
- The death of a few loved ones in a condensed timeframe
Insufficient coping skills including, but not limited to, addiction, dependency, etc.

These risks can heighten the grief reaction and indicate additional support may be necessary. Yet, keep cultural differences in mind.

“Some cultures encourage intense visual displays of emotion, which can be perceived as complicated grief, but this is normal grieving for them,” says Jessica. “When cultural differences may be involved, ask questions to learn more.”

For resources on grief and bereavement or to refer your hospice-eligible patient to VITAS, contact us today.

Choosing a Hospice Organization: Making Referrals That Most Benefit Your Patients

Tue, 30 Jul 2024 04:00:00 -0400

When your patient is seriously ill and hospice eligible, how do you know which hospice organization to refer to? Aren’t they nearly all the same?

All hospices must provide core services, but substantial variation exists in how hospices deliver these services. These differences can impact the quality of care for both the patient and their family or caregivers.

What is common for all US hospices is that the Medicare Hospice Benefit covers the costs of hospice services. Medicare Part A covers up to 100% of the costs related to a hospice-eligible patient’s terminal diagnosis, which indicates the patient has six months or less to live if the disease runs its typical course. Coverage includes everything involved in hospice care, from visits by a nurse, physician, and other healthcare professionals to therapy, medication, and supplies.

What to Expect: Core Hospice Services

Hospice is not a location. Team members can provide hospice care wherever the patient calls home—in a private residence, assisted living community, or skilled nursing facility. Common services that you can expect from most hospices include:

Advance care planning assistance and resources
Symptom management/pain relief that is not curative but enhances the patient’s quality of life
Clinical care provided by an interdisciplinary team, including physicians and nurses along with the services of home health aides and social workers
Emotional and spiritual support from bereavement specialists and/or chaplains for the patient and their families
Four levels of hospice care, including routine home care, continuous home care for up to 24-hours-a day when medically needed, general inpatient care, and respite care for the caregiver

Yet key differentiators can distinguish hospice providers, including their ability to respond 24/7/365, their expertise with high-acuity care, and their care coordination, along with their track record for compassionate care.

The VITAS Advantage: Supporting Clinicians While Caring for Patients and Families

What happens if a patient has an accident or emergency in the middle of the night? Rather than going to the ED, suppose the hospice provider can respond with clinical care? VITAS does, specifically offering:

24/7/365 clinical care support, including telehealth with around-the-clock access to clinicians for triage, assessment, and treatment guidance. Seamless care transitions are available at any time of day or night.
Care coordination that assesses and manages individualized patient care. VITAS interdisciplinary teams facilitate communication about patient care transitions, symptom management, health status, and quality of life.
Open formulary for individualized care plans, including continuation of disease-directed medications. A VITAS nurse supervises medications and compliance to mitigate chances of return to hospital/ED.
Complex modalities supported by physician/APRN home visits, aggressive symptom management: IV hydration/antibiotics, high-flow O2, Sub-Q Lasix, inotropic therapy, and more.
High-acuity care for patients with acute symptoms; intensive symptom management that aligns with patient care goals. VITAS supports a reduction in overall healthcare costs and reduces likelihood of readmissions associated with alternative post-acute care settings.
Advanced illness specialists who deliver customized educational plans based on practice needs and goals and clinical resources to enhance prognostication of advanced illness patients. Assist with goals-of-care conversations, specialist consults, medication reconciliation, and more.
Cultural competency, embracing diverse backgrounds and perspectives of those with whom we work and the patients and families we serve, regardless of age, gender, gender identity, ability, education, ethnicity, nationality, political opinion, professional experience, race, religion, sexual orientation, and socioeconomic status.

Selecting a Hospice: Helping Families Prepare

Once you determine a patient is hospice eligible, how can you guide family members to prepare for the next step of accepting a referral to hospice care? You can ask questions like these to encourage them to meet with a potential hospice organization:

Has your loved one talked to you or written down their wishes about care near the end of life?
- Less than 40% of Americans have not completed an advanced directive.
Have you discussed where they would like to receive care in their last months, weeks, or days?
- 70% of the population would prefer to die at home.
- Only about 1/3 pass in their homes.
Do you understand the four levels of hospice care?
Who will be the main caregiver for your loved one at home?
Have you discussed managing pain?
Have you talked about the spiritual needs of your loved one and your family? Do you know that emotional support is available to both you and your loved one?
Do you understand the Medicare Hospice Benefit and how hospice costs will be paid for?

It can be empowering to have options near the end of life. When a patient seeks a higher quality of life in their final months, weeks, and days, hospice may be their best choice. Selecting a hospice provider that can provide the 24/7/365 clinical support and compassionate care they need will enhance their experience—as well their caregivers’.

Support That Relieves Caregivers: How Hospice Helps Alzheimer's and Dementia Patients

Mon, 15 Jul 2024 04:00:00 -0400

By Joseph Shega, MD, EVP Chief Medical Officer, VITAS Healthcare

Today, an estimated 6.9 million Americans are living with Alzheimer’s or other dementias.¹ Many of these individuals have a spouse, family member, or other loved one assisting them with daily care. These caregivers help them move in and out of bed, dress, bathe or shower, and provide feeding and bathroom assistance. They coordinate care with other family members and healthcare providers and offer emotional support. This time-intensive caregiving for an individual with advanced dementia averages about 92 hours per month.¹

As their loved one’s illness progresses, these responsibilities can feel staggering, often leading caregivers to burn out. Studies show that people aged 65 and older survive an average of four to eight years after an initial diagnosis of Alzheimer’s, yet some live as long as 20 years.¹ In another study, well over half (57%) of family caregivers of people with Alzheimer’s or other dementias provided care for four or more years.¹

Stress on Alzheimer’s and Dementia Caregivers

The long-term effects caregivers experience when managing symptoms and assisting with activities of daily living (ADLs) for individuals with Alzheimer’s or other dementias can be significant. In a survey of caregivers for Alzheimer's and dementia patients, 74% reported they were “somewhat concerned” to “very concerned” about maintaining their own health since becoming a caregiver. In 2021, it was estimated that dementia caregivers bore nearly twice the average out-of-pocket costs of non-dementia caregivers ($12,388 versus $6,667).¹ The gradual progression of the disease causes an increase in stress and grief in caregivers, negatively impacting their physical, mental, and social health.²

Hospice Care: Relieving the Caregiving Burden

What offers relief?

Hospice services have proven to ease the caregiver burden on family members and support the patient with a personalized disease-directed care plan. VITAS interdisciplinary care teams consisting of a physician, nurse, home health aides, bereavement specialist, and chaplain respond to the clinical, psychosocial, and spiritual needs of the patient. The Medicare Hospice Benefit covers hospice costs related to the terminal illness for eligible patients, including medications and home medical equipment. For people living with advanced dementia, research demonstrates the value of hospice:

Hospice-enrolled people living with dementia had a higher quality of life compared to those without hospice.
End-of-life transitions (e.g., hospitalizations, ED visits, etc.) were significantly lower for hospice enrollees compared to those who were not.
Hospice beneficiaries saw a cost savings of $670 in the last month of life compared to non-hospice users. ^3-4

When clinical care is accessible 24/7/365 and home health aides visit regularly to assist with activities of daily living (ADLs), caregivers no longer shoulder the full burden of care.

Caregivers who utilized hospice reported⁵:

Increased satisfaction with care
Decreased burden
Decreased anxiety and depression
Improved overall health

Leaning on experienced hospice care team members helps avoid caregiver burnout. Also, caregivers experienced less risk for PTSD with home hospice deaths as compared to the ICU, and home hospice reduced the risk for prolonged grief disorder compared to hospital deaths.⁶

Emotional Support: Dealing With Anticipatory Grief

VITAS grief and bereavement experts help caregivers, other family members, and the patient through the beginning stages of grief. Patients with advanced illnesses such as Alzheimer’s or dementia and their loved ones usually begin the grieving process before the actual loss occurs. This is called “anticipatory grief.”

Although it may be uncomfortable, anticipatory grief is sometimes helpful. It is a natural process that helps individuals prepare for emotional and physical closure. It is also a time when both patient and family prepare for change. Having expert support during this sensitive time can be comforting.

Drawing on the Full Support of Hospice Services

Helping caregivers navigate the challenges of advanced dementia is best before they experience burnout. VITAS is ready to assist hospice-eligible patients in improving their quality of life—and supporting family caregivers in maintaining theirs as well.

Learn more about Hospice Care for Alzheimer’s Disease and Dementia.

¹ Alzheimer’s Association. (2024). Alzheimer's Association 2024 Alzheimer's Disease Facts and Figures. Retrieved 5/31/2024.
²Vu, M, et al. (2022). Impact of Alzheimer’s Disease on Caregivers in the United States. Health Psychology Research. 2022;10(3). doi:10.52965/001c.37454
³Harrison, 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.
⁴ Aldridge, et al. (2022). Association between hospice enrollment and total health care costs for insurers and families, 2002-2018. JAMA Health Forum. 3(2), e215104-e215104.
⁵Irwin, S., et al. (2013). Association Between Hospice Care and Psychological Outcomes in Alzheimer’s Spousal Caregivers. Journal of Palliative Medicine, 16(11), 1450-1454
⁶ 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.

Reinforcing Hospice Facts: Hospice and the Use of Morphine

Thu, 13 Jun 2024 04:00:00 -0400

By Maite Hernandez, RN, National Director of Sales Training, VITAS Healthcare

The truth is that not everyone on hospice services receives morphine. The administration of morphine or any other medication in hospice care depends on the individual needs and symptoms of each patient. Morphine is commonly used in hospice care to manage severe pain and shortness of breath, but it is not given to all patients receiving hospice services.

What Is Morphine? Why Use It at All?

Morphine is a powerful, effective medication used to relieve severe pain and other symptoms. While a common misconception about morphine is that it is used primarily in hospice, morphine is also used in various other medical settings.

For example, morphine is often used in hospitals to manage pain after surgical procedures, accidents, fractures, or other traumatic injuries. Individuals who suffer a myocardial infarction (heart attack) may require morphine to manage severe chest pain and anxiety. In these settings, morphine is administered in the vein (IV) or subcutaneously (Sub Q). No matter the location of care—whether it is in a hospital, palliative care, or at home on hospice—the goal when administering morphine is to maximize patient comfort, ensure safety, and minimize the risk of side effects and/or complications.

Individualized Plans of Care

Hospice care focuses on providing comfort and improving the quality of life for patients with advanced illnesses. The clinical care team, which typically includes doctors, nurses, and other healthcare professionals, works closely with the patient and their family to determine what their care goals, wishes, and preferences are and develops a personalized care plan that addresses the patient's specific symptoms. This individualized care plan may or may not include morphine, depending on what is best for the patient's comfort and symptom management. If the care plan does include morphine, the dosage is carefully titrated to achieve symptom relief and comfort while minimizing side effects.

To empower patients and families in their serious illness continuum and ease their concerns about the common misconceptions of hospice care and the use of morphine, the VITAS clinical team provides ongoing education focused on the patient’s symptoms and on the medication(s) prescribed. As families receive this education and support, they have opportunities to ask questions and learn what to expect. This may include discussing how morphine works, its benefits, potential side effects, and more.

How Pain Medications Help Hospice Patients

Contrary to common beliefs, hospice is not the end. It's not giving up. It's the beginning of a new journey. When morphine or other pain medications are prescribed appropriately, patients can experience relief from pain, leading to better quality of life. The hospice clinical care team works diligently with expertise and compassion so patients can spend the time they have left enjoying the people and things they love most.

Why Reinforcing Hospice Facts Is Important

Many people have misconceptions about hospice care, such as believing it is only for the very last days of life or that it means giving up on treatment. Research published in the Journal of Pain and Symptom Management found that Medicare beneficiaries who opted for hospice care lived an average of 29 days longer than similar patients who did not take advantage of hospice.¹ In reality, “greater utilization of hospice during the last six months of life is associated with improved patient experience and clinical outcomes.”²

Reinforcing the facts about hospice can help correct these misunderstandings. Hospice-eligible patients deserve to have the opportunity to receive accurate and timely information about the Medicare Hospice Benefit and their right to access it earlier in their disease trajectory. Making timely, informed decisions about end-of-life can help families prepare and align care with the patient’s care goal wishes, values, and preferences.

¹ Connor, S., et al. (2007). Comparing hospice and nonhospice patient survival among patients who die within a three-year window. Journal of Pain and Symptom Management, 33(3), 238-246.
² 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.

Staying Prepared to Care During Hurricanes and Other Natural Disasters

Wed, 12 Jun 2024 04:00:00 -0400

By VITAS Healthcare, Senior Vice President of Operations, Central Florida, Jennifer Nygaard

When a hurricane barrels toward the Florida mainland, VITAS mobilizes on behalf of our patients and team members to help secure their safety. Planning, careful strategizing, and diversified communications enable us to respond to natural disasters while maintaining a high level of quality care throughout the crisis.

Case in point: Hurricane Irma hit Florida in September 2017 as a Category 4 storm, leaving two thirds of the state without power. VITAS leaders had already deployed the VITAS Comprehensive Emergency Management Plan when it arrived.

Hurricane Irma: A Case Study in Preparation

Before hurricane season begins, VITAS holds an emergency preparation call with leadership to align priorities and resources. Once we see a service area is in a "watch" location, the Operations leadership team and all corporate departments meet daily to collaborate. Our field programs do the same as they review emergency processes. Hurricane drills, which take place prior to June 1 each year, keep our teams prepared.

When a threat escalates, as in the case of Hurricane Irma, daily preparation calls increase to several times a day. We tap into our Care Connection Center as well as our pharmacy, facilities, admissions, communications, employee relations, and human resources teams, among others, to ensure we are in sync with our ability to provide for our patients.

For example, our durable medical equipment (DME) division runs reports that list all patients who have portable oxygen needs and a generator or back-up power support. From there, we determine a delivery schedule for portable O², working together to ensure this transaction is seamless. Team members check if the patient will remain at the address and if a caregiver will be home to accept the delivery.

Typically, we also place extra medical supplies and water at locations outside the storm’s projected path for post-storm delivery to affected areas.

Assessing Risks to Team Member and Patient Safety

We keep track of each storm’s path, including when and where it is likely to make landfall. Our pharmacy team ensures we have local access to fill medications, so families have what they need until the storm passes. We follow a similar process with medical supplies.

In the meantime, we monitor wind speeds. Our delivery trucks cannot drive when the winds reach high speeds. Throughout Florida, bridges spanning the St. Johns River, Banana River, and Intracoastal Waterway close when wind gusts surge. Our window of time to get to our patients, deliver necessary supplies, and move patients to a safer location is narrow.

When Hurricane Irma swept across the state, few areas were untouched. As the New York Times reported, the state ordered mandatory evacuations in 16 Florida counties and voluntary evacuations in 13 more as Irma drew near.

We moved patients who resided in evacuation or flood zones based on their emergency plan form completed at admission. Many of these patients went to a hotel, shelter, or family member’s home outside of the storm area; we placed others in respite care inside a nursing home in a safer location. VITAS inpatient units (IPUs) are often full during these crises, so we arrange for our team members to remain there in shifts for their own safety and that of our patients.

During the Storm: Overcommunication Is Key

If VITAS team members are trapped by floods, find themselves unable to get food, need rescuing, or require help with housing, they contact our emergency staff number. We train our employees to remain calm and communicate several times a day with their management team about patient needs as well as their own. We balance ensuring our staff is prepared to respond to patients with their own safety and security, including following all county and state guidelines for traveling on area roads.

In addition to our local team members, our Telecare service monitors patients 24/7/365 from multiple locations throughout the country.

During Irma, when some areas of the state were completely flood-bound, VITAS patients spent their last days in clean, safe surroundings with their loved ones and our continuous care teams by their sides. We worked closely with emergency response teams including police, fire, the sheriff’s office, and the coast guard to make arrangements.

After the Storm Passes: Addressing Practical Needs

In the event of a mass power outage, our team members have no way to get fuel in their vehicles to go to see patients. During Irma, VITAS moved our fuel truck across South and Central Florida for team members to fill up their cars. This allowed them to care for their own needs while continuing to visit patients.

As the storm subsided, we checked our offices for damage and tested the power. If the office was secure and had power, we issued a return-to-work message via our phone trees. From there, we checked on every single patient again and followed up with patients who called during the storm.

VITAS has cared for Floridians through 45 hurricane seasons and counting. This depth of experience has enabled VITAS to develop a solid process for managing emergent and pivotal crises during our patients’ hospice journey.

With hospice services in 15 states and the District of Columbia, VITAS can reposition and temporarily allocate team members to support VITAS locations throughout the country—both in person and remotely—so that our patients continue to receive high-quality care.

Advocating for the Distinct Needs of Veterans Nearing End of Life with We Honor Veterans

Wed, 29 May 2024 04:00:00 -0400

By Larry Hetu-Robert, Bereavement Services Manager and Veterans Liaison, VITAS Healthcare

As healthcare professionals, our duty extends beyond just providing medical care; it's about understanding and addressing the unique needs of each individual, especially when it comes to our nation's veterans. At VITAS® Healthcare, we take pride in our national involvement with We Honor Veterans, a program of the National Hospice and Palliative Care Organization (NHPCO) that collaborates with the Department of Veterans Affairs (VA) to empower hospice care providers to meet the distinct needs of veterans and their families as they approach the end of life.

Veterans deserve equal and early access to specialized end-of-life care, and our participation in the We Honor Veterans program reflects our commitment to that belief. We Honor Veterans distinguishes the quality of veteran care provided by their hospice care partners through a level grading system, with the highest level of care quality being Level 5. To date, 78% of our programs across the nation are either a Level 4 or a Level 5. We undergo rigorous annual evaluations to ensure that we can continuously meet the highest standards of care for our veteran patients.

“Becoming a community partner with We Honor Veterans demonstrates our programs’ commitment to comprehending the essence of a veteran's journey. Our dedicated team delves into the narratives, valor, and the profound significance of each veteran’s military service,” says Mario Lopez, a VITAS Regional Director of Market Development and Army veteran who served in Afghanistan.

Uncovering Unique Needs for Individualized Care

So, what sets VITAS apart in caring for veterans nearing the end of life? It starts with our specialized training and expertise. Our teams are equipped with the knowledge and skills to address not only the physical needs of veterans but also their psychosocial needs. We understand that veterans may carry unique burdens, such as post-traumatic stress disorder (PTSD), moral injury, military sexual trauma, and more. That's why we provide specialized training in sensitivity to trauma and the nuances of different military eras, such as the Vietnam War, the Korean War, and World War II.

VITAS takes a streamlined approach where veterans are identified early through an initial comprehensive assessment. We use tools like the military history checklist to dive into their history, including military occupational skills, rank, any decorations, and/or participation in specific military campaigns, which allows us to tailor our care plans to their specific needs. Whether it's recognizing the effects of Agent Orange exposure or addressing combat-related guilt and moral injury, we're dedicated to providing holistic care that honors the service and sacrifices of each veteran.

We Honor Veterans Level 5: Advocating, Engaging, and Mentoring

Recognition as a Level 5 hospice partner with We Honor Veterans comes from the completion of educational training, community engagement, volunteer programs, and data collection. Serving as a mentor to community organizations and other hospice care providers is a key step in receiving Level 5 designation. We actively collaborate with community partners, veteran organizations, and the VA to ensure that veterans receive the full range of benefits and support available to them. From hosting educational events to facilitating VA referrals and providing access to additional resources, we're here to advocate for our veteran patients in every step of their hospice journey.

Concurrent care allows veterans to receive the curative medical treatment offered by the VA alongside comfort-focused hospice care. Working in conjunction with the VA, we remain committed to providing flexible and personalized care options that prioritize the individual needs and preferences of each veteran we serve. By combining the expertise of our team with the resources of the VA, we ensure that veterans receive the holistic support they deserve as they navigate the final stages of serious illness.

Making Real Impact

Through our efforts, we have made a meaningful difference in the lives of veterans and their families. From honoring Pearl Harbor survivors on the field at an Atlanta Braves game to assisting veterans in securing long-overdue compensation, we are always committed to veteran-centric care.

It's not just a responsibility; it's a privilege to serve those who have served our country with honor and valor. At VITAS, we stand ready to support veterans and their families with the dignity, respect, and care they deserve.

Mario adds, “The end-of-life experience, rather than being a mere passage, transforms into a meaningful culmination of memories, respect, and honor.”

Hospice Volunteers Elevate the Patient and Caregiver Experience

Fri, 19 Apr 2024 04:00:00 -0400

VITAS volunteers provide emotional support to patients, relieve strain on caregivers and sew Memory Bears—tangible, huggable mementos made from patients' clothing.

By Patty Husted, Executive Vice President, Patient and Family Supportive Services, VITAS Healthcare

Hospice care is a purposeful choice to enhance the quality of life for patients with serious illness and their caregivers. Clinical excellence is one aspect of quality hospice care. Supportive services, such as volunteer assistance, are another. These helpful individuals uplift patients nearing the end of life, provide relief, and run errands for their caregivers.

Hospice volunteers play a crucial role in enhancing the care experience for patients and their families. Their dedication and compassion contribute significantly to the well-being of those receiving end-of-life care. Volunteers provide support simply by being present, listening, and offering comfort during this time of need.

Holding a patient’s hand or offering a kind word can bring immense solace. Some volunteers assist with simple homemaking tasks, such as light housekeeping or getting necessary items, to alleviate some of the caregiver’s burdens and ensure the patient’s environment remains comfortable. Volunteers can also assist with feeding, which eases the workload for caregivers.

Volunteers are so vital to the end-of-life care experience that the Medicare Hospice Benefit requires that volunteer hours equal at least five percent of the hospice provider’s total patient care hours. Yet, increased volunteer hours may be even more impactful, whether volunteers serve in patients’ homes, senior living communities, or inpatient units. In a cross-sectional study, researchers found, “hospice programs with higher use of volunteers per patient day were associated with bereaved family member reports that the hospice program quality of care was excellent.”¹

Integrating this supportive care with the clinical and spiritual aspects of hospice services is shown to increase the satisfaction of both patients and caregivers.

Assistance for Caregivers and Patients: Volunteers Support the Care Experience

According to the family members surveyed, “one of the most important types of support hospice palliative care volunteers provide is allowing them to take a much-needed break.”² By offering relief visits, volunteers give caregivers the opportunity to rest, attend to personal matters, or recharge, knowing their loved one is in good hands.

Away from the bedside, volunteer sewers create meaningful legacy gifts by assembling articles of loved ones' clothing into keepsakes. These crafted items provide comfort and solace to grieving families. Volunteer sewers invest their time, creativity, and care into each piece, understanding the profound impact it will have on the bereaved.

“VITAS specialty volunteers include sewers who create Memory Bears or Memory Pillows for loved ones and caregivers,” said EVP Patient & Family Supportive Services Patty Husted. “Volunteers also craft fidget aprons and squares for our dementia patients. These tactile toys help keep them calm.”

While VITAS does not count these crafting hours toward the 5% of volunteer hours mandated for hospice providers by the Medicare Hospice Benefit, their significance as a legacy to caregivers is everlasting. “My parents have been gone for 13 years, and I still have the Memory Bears placed prominently in my home,” said Patty.

In 2023, more than 3,100 VITAS volunteers spent 229,132 hours caring for almost 5,000 VITAS patients. VITAS volunteers made 7,380 Memory Bears, pillows, and quilts.

Donating their time and talents, volunteers serve in many capacities, including:

Life Bio™ volunteers listen to patient stories to create a legacy booklet of the patient’s life.
Musical Memories volunteers play music reminiscent of an earlier time in the patient’s life, bringing up memories to share. Sometimes dementia patients will start singing to a familiar tune.
Remote volunteers assist by picking up and then delivering supplies to the patient’s home.
Haircare volunteers pamper patients by cutting and styling hair.
VITAS Individualized Pampering (VIP) program volunteers may provide fingernail painting, hand care, arts and crafts, or interactive activities like music or games. A questionnaire identifies which pampering activities a patient would most enjoy.
Bereavement Telephone Assurance Program (BTAP) callers check in on the primary caregivers after the patient’s death to provide a listening ear and condolences. Bereavement volunteers also schedule in-person visits.

“As a volunteer, I’ve offered services including companionship, holistic care (therapeutic massage, healing touch, breathing meditation, chair yoga, active listening), and spiritual care,” says VITAS Volunteer Aruni Marapane. “Some families have contacted me, saying the end-of-life experience they went through with their loved one was positive and sacred because of my participation. It is an honor and indeed a privilege.”

Special Acts of Service: 11th Hour and Veteran Volunteers

Individuals who feel comfortable sitting with a patient as they are actively dying are called “11th Hour” volunteers. They stay with patients so they do not die alone.

“Sometimes veterans in uniform will sit vigil at the bedside to ensure that if there's no family or if family members can't be there, they are present for their fellow serviceperson,” said Patty. Several VITAS programs also work with veterans to arrange a bedside veterans salute.

Two VITAS team members participate in a veteran patient's bedside salute.

This 11th Hour service extends beyond veterans as well. “Family members and caregivers thank me for being there to ease their worries,” says 11th Hour Volunteer Karen Lesniak. “One patient moved, and her hand ended up in mine. I thought it was accidental and started to take my hand away, but then I felt a grasp. It was very moving. Her family was out of state and rushed home to see my compassion shared with their mother. They were grateful she was not alone.”

Often, what drives these volunteers is personal experiences that invite empathy and service. “All of the losses of my closest loved ones have been sudden, shocking, abrupt, and unexpected,” says Karen. “I felt my time and presence was a beautiful way to help provide a break for families, and especially for patients who have no family around.”

Lightening the Load for Caregivers

Caregivers shoulder an incredible responsibility as they assume everyday care for their loved one with advanced cancer, heart disease, COPD, or other serious illness. A study in The Journal of Pain and Symptom Management states, “Around two million family caregivers assist with end-of-life symptom management annually, of whom 78% report difficulty.”³

Caregiving for those with Alzheimer’s or other dementia can be even more taxing. “The amount of time required for caregiving increases as dementia progresses; one study showed that people with dementia required 151 hours of caregiving per month at the outset of dementia, and this increased to 283 hours per month eight years later. This is an increase from approximately five hours a day to nine hours a day.”⁴

VITAS interdisciplinary teams support patients and their caregivers with 24/7 access to clinical care, including psychosocial and spiritual services. Having a team to lean on eases the pressure on caregivers and helps them navigate the unknowns during the end-of-life process.

“I think the hardest thing to hear from family members is, ‘I wish I knew of you sooner,’” says Patty. “People are scared, they're not sure what's going to happen, and it's the unknown that troubles them.”

When a parent, spouse, child, friend, or other loved one enters the end-of-life process, the emotional and physical rigor involved can be overwhelming. Hospice comes in to provide clinical help, supportive services, and team assistance to improve the experience for both patients and caregivers.

¹Block, et.al. (2010). Got Volunteers? Association of Hospice Use of Volunteers with Bereaved Family Members’ Overall Rating of the Quality of End-of-Life Care. Journal of Pain and Symptom Management. 39(3), 502-506.
²Claxton-Oldfield, et.al. (2010). A Survey of Family Members’ Satisfaction With the Services Provided by Hospice Palliative Care Volunteers. American Journal of Hospice and Palliative Medicine. 27(8) 557-800.
³Mather, et. Al. (2022). Symptom Management Experience of End-of-Life Family Caregivers: A Population-Based Study. Journal of Pain and Symptom Management. 64(6):513-520.
⁴ 2024 Alzheimer’s Disease Facts and Figures. Retrieved March 22, 2024 from Alzheimer's Association 2024 Alzheimer's Disease Facts and Figures.

Why VITAS Offers an Open Formulary and How It Benefits Patients

Tue, 16 Apr 2024 04:00:00 -0400

By John Pagliano, Vice President, Pharmacy, VITAS Healthcare

Medications can be a lifeline for patients with a serious illness, reducing their pain and providing relief from symptoms. Appropriate drug therapy increases their comfort and enhances their quality of life. Ensuring that end-of-life patients receive necessary medications eases their stress—and the family caregivers’—during a vulnerable time in their lives.

To provide proper drug therapy, clinical hospice experts create a plan of care related to the patient’s advanced disease state. While no longer treating the disease itself, the hospice orders, pays for, and arranges delivery for medication related to the terminal diagnosis as described in the plan of care. The Centers for Medicare & Medicaid Services (CMS) require this provision of medication for palliating the symptoms of terminal illness and related conditions in hospice.

The Value of an Open Formulary

VITAS offers an open formulary for hospice patients. To my knowledge, VITAS is the only hospice provider that offers an open formulary as of this writing.

Why would patients and families prefer an open formulary?

All insurance companies and nearly all hospices use a closed formulary and only pay for certain drugs, which are mostly based on cost. If a medication falls outside their formulary, the provider requires prior authorization and/or step therapy, which means the patient must try alternatives first before the provider approves a nonformulary drug. Most drugs outside the formulary are not approved.

With an open formulary, VITAS pays for any drugs related to the terminal diagnosis and associated conditions that the physician deems necessary. If these medications are the proper therapy and follow the physician’s plan of care, they are automatically approved. They require no further authorization.

The open formulary includes both brand and generic options. If generic is available, it is used first.

Data indicates the probability of patient rehospitalization decreases with access to an open formulary and proper plan of care. If a patient is already in the hospital—yet not on hospice—they can shorten their length of stay through a physician discharge into hospice with an open formulary, following their plan of care.

Why Medication May Change in Hospice

Medications used to treat symptoms of a terminal diagnosis may change as a patient ages and their disease state alters the body. For example, the vast majority of COPD patients can no longer use a handheld inhaler. Their dexterity and ability to coordinate an inhaler are no longer effective. In these cases, VITAS will provide other therapies to treat symptoms, such as nebulizers or oral steroids.

Pharmacology looks at four phases of drug therapy, summarized by the acronym ADME:

How the body absorbs the medication (absorption)
How it is distributed through the body (distribution)
How the body metabolizes the drug components (metabolism)
How the body eliminates or excretes the drug (elimination)

In hospice, physicians weigh the risk versus the reward of medication as they consider its side effects. For example, when prescribing anticoagulants, clinicians would assess the risk of stroke against that of a brain bleed from a fall. Additionally, some drugs are no longer effective in the late stages of disease and create untoward side effects such as nausea and vomiting.

At multiple points in the care process, clinicians evaluate the drug therapy protocol. When admitted to hospice, VITAS physicians make an initial assessment and create a plan of care for the patient. This plan is constantly evolving. Nurses update plans of care weekly, and the interdisciplinary team discusses the plans biweekly in their team meeting. A caregiver’s alert or patient change of status also triggers an adjustment to the plan of care.

Typical Hospice Drug Therapies

CMS regulations state medication therapy in hospice must palliate a symptom, not treat the disease causing it. This means, for instance, that immunotherapy for cancer is considered a treatment and not palliation because it is not symptom-related and would not be approved.

In some instances, disease-directed treatment may provide palliation of a symptom. Hormonal therapy for prostate cancer may be palliative, so it can be approved.

As directed by CMS, four classes of drugs are approved and paid for by hospice for any reason:

Pain management
Anti-anxiety
Bowel regimen
Nausea and vomiting

Payment and Delivery: Reducing Stress for Patients and Caregivers

VITAS nurses profile all patient medications and review them during every visit to facilitate refills, complaints, compliance issues, and confirm effectiveness. VITAS provides all prescriptions and medications related to a hospice patient’s terminal diagnosis:

Regardless of formulary
In a timely manner
With no roadblocks

Enclara, our pharmacy partner, is regulated under standard federal and state laws related to pharmacy and audited by their parent company Humana as well as the VITAS pharmacy division. If a nursing home mandates the use of their pharmacy provider, VITAS facilitates access and bills this through our pharmacy benefit manager.

Patients receive most medication either through mail order or delivery by a VITAS courier or team member. Maintenance medications arrive through next-day mail order. Emergency or stat needs typically are funneled through the local network of contracted pharmacies and may be picked up by the family caregiver or patient, if able.

For those who live in areas of diversion risk, safe delivery may involve:

Required signature for mail order delivery
Office delivery and team member drop off

For pharmacological needs unrelated to the terminal diagnosis and related conditions, the patient or caregiver obtains and pays for these medications. Drugs not related to the terminal process can be paid for by:

Medicare Part D
Medicaid
Other insurance
Out of pocket

VITAS clinicians do monitor the use of non-related drugs for their effectiveness and potential to cause a hospitalization or disease/drug interactions. Overall, compliance with the approved and appropriate drug therapy can prevent rehospitalizations.

Polypharmacy and Deprescribing

Polypharmacy, or the use of multiple drugs, causes some or all of the following:

Delirium
Cognitive deficits
Confusion
Falls
Dizziness
Drop in blood pressure
Reduced appetite
Constipation

Deprescribing is the hallmark of any proper therapy—and most important in hospice. Clinicians discuss reducing the pill burden with the patient nearing the end of life often to increase their quality of life.

Nonpharmacological Interventions

Too many times we rush to drugs to solve a patient’s discomfort. Nonpharmacological interventions offer all the benefits without the side effects of drugs. Here are a few options:

Terminal secretions generally don’t bother the patient but may trouble their family or caregiver. Medications used for secretions have side effects and can contribute to confusion and delirium in the late stages of disease. Proper positioning of the patient on their side with their head slightly elevated and a towel beneath the mouth will allow secretions to more readily drain out without pharmacologic intervention. Nurses train family members on how to position the patient into this recovery position.
A nasal gastric tube can be placed to reduce nausea and vomiting with no side effects.
Portable fans on the side of the bed are for patients with air hunger or shortness of breath that are not hypoxic. These fans augment medications by producing a wave of air, providing the illusion of better intake and reducing anxiety.

A more comfortable patient is a happier patient. Pharmacological and nonpharmacological interventions in hospice treatment provide palliation of symptoms—and this is what the patient with serious illness desires.

Does Your Patient Need Home Health, Palliative Care, or Hospice Care?

Thu, 29 Feb 2024 05:00:00 -0500

By Jennifer O’Neill, National Director, Palliative Care, VITAS Healthcare

Suppose your patient with serious illness—COPD, heart failure, cancer, dementia, or other—requires more support than you can provide. Based on their current stage of disease, how do you determine whether home health care, palliative care, or hospice is the optimal referral?

Streamlining the Continuum of Care

Home health, palliative care, and hospice provide different levels of care and have separate eligibility requirements.

Home health is designed to treat an illness or injury and help patients with optimal restorative potential. Skilled home health services include wound care, injections, intravenous or nutrition therapy, and monitoring a patient’s health status. These services are not equipped to provide the higher levels of clinical or psychosocial care that palliative care or hospice offers or meet the complex needs of high-acuity patients.

Palliative care is for patients who are less responsive to disease-directed treatments yet have a prognosis of 18 months or less. VITAS palliative care offers expert case management and care coordination in alignment with patients’ care plans, values, and goals. It ensures patients’ comfort and quality of life while supporting patients’ and primary care physicians’ desired outcomes.

In palliative care, VITAS clinicians help patients recognize where they are in the disease trajectory, available treatment options, and the benefits of hospice care, if appropriate. If the patient has not identified their goals of care, the clinician will initiate ongoing conversations about preferences for care. Advance care planning enables patients to document their goals, including code status/DNR, the use of artificial nutrition/hydration/feeding tube, name a healthcare designee, create a living will, and submit a Physician Orders for Life Sustaining Treatment (POLST) form.

Signs that a patient may need a referral to palliative care include ongoing decline, increased healthcare utilization, and complex requirements at home, among others.

Hospice is for patients who are not responding to disease-directed treatments. If their illness takes the expected trajectory, these patients have six months or less to live. In hospice care, a VITAS interdisciplinary team (including a physician, nurse, aide, social worker, chaplain, volunteer, and others) creates a personalized plan of care for the patient, including psychosocial and spiritual support.

Importantly, VITAS hospice care offers 24/7/365 clinical support, reducing the probability of hospital readmissions or more visits to the ED. Hospice services come to the patient, so the patient can remain in the setting of their choice, whether that is a private home, assisted living community, or nursing home.

The VITAS hospice clinical team provides disease-specific expertise for symptom management and arranges for medications, home medical equipment, and supplies to be delivered to the patient’s home. High-acuity and complex treatments (such as parenteral therapies: antibiotics, TPN light and hydration, inotropes, high-flow oxygen, PT/OT, and speech) are also available.

Hospice is the only one of the three options covered by the Medicare Hospice Benefit (Medicare Part A). If a patient meets hospice eligibility, hospice may be the right next choice for them.

Discussing Care Options with Your Patients

Initiating next-step conversations with your patients and their families is vital. Though it may be easier to discuss home health or palliative care options, goals-of-care conversations help ensure that your patient’s preferences are honored as their illness advances.

Take the time to discuss and ascertain your patient’s goals, wishes, and values for their care. If they have a health crisis, a hospital clinician will likely bring it up instead. Having this discussion with their own healthcare provider who is familiar with them adds comfort to an often-uncomfortable decision.

An annual wellness visit or a post-hospitalization follow-up offers the opportunity to introduce palliative care as an option. When approaching potential hospice enrollment, VITAS can assist you in navigating common misconceptions so your patient can make a timely transition to hospice care.

Making the Right Choice Sooner: Maximize Benefits for Your Patients

Along with choosing the right referral option, when to refer is critical. Often, patients don’t receive palliative or hospice care soon enough. When they don’t, they miss out on the full services that help improve their quality of life.

Palliative care supports longer lengths of stay. The prognosis for palliative care patients is 18 months or less, and support services become available at the diagnosis of serious illness. As the patient declines, hospice becomes a natural and seamless transition.

Yet the transition to hospice is often delayed longer than necessary. According to the NHPCO, the median length of stay for hospice is 17 days¹ (a decrease from a consistent 18 days over the last five years). This means most Medicare decedents and their caregivers don’t get access early enough. Because hospice eligibility begins at a prognosis of six months or less, these patients and their families could have received quality-of-life enhancing hospice services weeks, perhaps months, earlier.

Further, studies show that families of patients receiving greater than 30 days of hospice reported the most positive end-of-life outcomes.

For a palliative care consultation or to refer a patient for hospice, contact VITAS. VITAS also supports you in initiating goals-of-care conversations.

1. NHPCO. (2023). Facts and Figures: Hospice Care in America.

VITAS Patient-Centered Care: 4 Levels of Personalized Care

Mon, 04 Mar 2024 05:00:00 -0500

By Bryan Wysong, Senior Vice President, Operational Performance, VITAS Healthcare

Individuals facing serious illnesses may be approaching the final phase of their healthcare journey. Nevertheless, every patient deserves quality of life focused on what matters to them. For patients like these, VITAS® Healthcare offers four levels of care to ensure their final months, weeks, and days can be meaningful and fulfilling in their location of choice.

In addition to managing symptoms, hospice helps patients address spiritual needs as well as financial, practical, and relational matters. Making this part of their journey the best it can be—for both patients and their loved ones—drives my passion for hospice care.

Because VITAS elevates the level of care based on the patient’s need, we can reduce disruptive rehospitalizations and Emergency Department (ED) visits. Typically, patients receive clinical care in the comfort of their own home or other preferred setting. This eases their anxiety and offers loved ones’ peace of mind.

A Higher Level of Care: Four Levels Based on Patient Need

The Medicare Code of Federal Regulations (CFRs) requires hospices to provide four levels of care: hospice care at home, continuous hospice care, inpatient hospice care, and respite care.

Four Levels of Care Mandated by the Medicare Hospice Benefit
Home/Routine	Most common level of hospice care More robust and comprehensive compared to home health services Patient's preferred setting and no homebound requirement Proactive clinical approach helps prevent ED visits/hospital readmissions
*Continuous Care (at VITAS, we call this Intensive Comfort 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
Inpatient	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
Respite	Provides temporary break (for caregiver burnout, travel, work, etc.) Up to 5 days of 24-hour patient care Medicare-certified hospital, hospice facility, or long-term care facility

While every Medicare-certified hospice provider must provide all four levels of care, in reality, not all hospices do. Based on data from the Centers for Medicare & Medicare Services (CMS), fewer than 28% of hospices reported providing continuous home care in 2022¹. Over the last four years, the number of hospice providers reporting no instances of continuous home care, inpatient respite care, or general inpatient care has steadily risen.

Selecting a hospice provider that does not provide high-acuity care can impact the patient and caregiver experience. According to CMS, “Hospices that are unable, or unwilling, to provide higher levels of care… may not adequately be able to care for patients who are in crisis or have symptoms that cannot be managed in the home, resulting in a worse outcome for the patient [and] a greater burden on caregivers which may worsen the quality of care at the end of life.”

Continuous Care vs. Inpatient Care

Continuous care and general inpatient care are similar. Both are designed for patients in a crisis who require a higher level of clinical assistance. Once a patient’s acute symptom exacerbation is resolved, patients are transitioned to a routine level of hospice care.

They differ in that general inpatient care must be provided in a skilled setting, such as a hospital, nursing home, or freestanding hospice facility.

Continuous home care, as its name suggests, offers this higher level of care in a patient's residential home or home-like environment, such as an assisted living community or nursing home. The VITAS care team provides shifts of care, which can be up to 24 hours a day.

Most commonly, LPNs care for patients along with HHAs. In addition, an RN will either visit in person daily or check in remotely. The patient benefits from the services of their entire interdisciplinary team, including an RN case manager, chaplain, social worker, and volunteers. At this higher level of care, their physician may also visit.

In 2022 alone, VITAS provided more than 1.3 million hours of continuous care shifts to its patients to manage acute symptoms in order to keep patients in location of choice.

Specialized Services Tailored to a Patient's Need

Along with expert clinical care, a personalized plan of care also includes specialty hospice services to ease symptom burden and provide an elevated patient care experience. To address specific patient needs, VITAS offers*:

Respiratory therapy
Physical therapy
Occupational therapy
Speech therapy
Music therapy
Dietary support
Nutritional counseling

These services are arranged as needed by VITAS team members.

^{*Some services vary by program.}

Expert Care Coordination Enhances Patient and Family Satisfaction

To ensure patients seamlessly transition to hospice care, VITAS coordinates care that aligns with the goals and wishes of the patient and their family. VITAS team members are responsible for:

Sharing information with patients’ attending physicians
Keeping patients and families informed of changes to the plan of care
Managing timely transitions between care settings
Providing the right care at the right time, in patients’ preferred setting

Our enhanced care coordination addresses the complexity of patients’ needs, including the provision of HME, supplies, and medications. VITAS has technology to facilitate coordination between hospice care teams and attending physicians, even for patients who see multiple healthcare professionals associated with several health systems.

Why Sooner Is Better for Hospice

Recent studies show hospice care improves patient outcomes—better symptom relief, goal attainment, and quality of life—with hospice stays over 30 days resulting in the highest quality of life outcomes.

Hospice offers multiple benefits to patients, families, and caregivers: increased satisfaction and quality of life, improved pain control, reduced physical and emotional distress, and reduced prolonged grief and other emotional distress.

1. Centers for Medicare & Medicaid Services (U.S.). (2023). Medicare Program; FY 2024 Hospice Wage Index and Payment Rule Update, Hospice Conditions of Participation Updates, Hospice Quality Reporting Program Requirements, and Hospice Certifying Physician Provider Enrollment Requirements. Dept. of Health and Human Services, Centers for Medicare & Medicaid Services.

Dr. Joseph Shega Talks Normalizing Death and Making Hospice Better on 'A Question of Care'

Mon, 19 Feb 2024 05:00:00 -0500

Conversations about hospice are also conversations about aging—how we think about it, how we prepare for it, and how we honor our responsibility to care for our country’s aging population.

With these conversations in mind, VITAS Chief Medical Officer Joseph Shega, MD, joined aging and caregiving expert Robert Espinoza on the podcast A Question of Care. The pair discussed the challenge of changing attitudes toward end-of-life care, the COVID-19 pandemic’s impact on the hospice sector, and improving end-of-life care experiences across the country.

Click here to listen to the podcast or read the transcript below.

Transcript

Robert Espinoza: How did the wealthiest country in the world get to a point where it can't support the health and long-term care needs of more than 54 million older adults? Welcome to A Question of Care™, a podcast that explores the many answers to this question through different viewpoints and topics. I'm your host, Robert Espinoza, a national expert and frequent speaker on aging, long-term care, and the workforce.

In this episode, we'll delve into the culture, perspectives, and practices related to death and dying in the U.S. Joining us is Dr. Joseph Shega, a professional with more than two decades of experience in this field who will be our trusted expert as we navigate this topic.

Dr. Joseph Shega: I am Joseph Shega. I am the chief medical officer for VITAS Healthcare.

Robert Espinoza: People in this country view death and dying from a range of perspectives, often reflecting their cultural, spiritual, or scientific viewpoints. While attitudes toward death vary widely, there are some overarching trends that we should explore.

Dr. Joseph Shega: So, over the 25 years, I would say the one thing that's remained consistent is death and dying still seems to be a taboo topic. People still don't feel comfortable talking about something that's gonna happen to all of us. So we continue to work hard every day to engage in conversations and normalize the conversations, recognizing that for better or worse, we're all going to face serious illness and end of life, whether it's our parents or ourselves or other family members or friends.

And so being open and having honest conversations and normalizing those conversations is our hope to try to continue to get people more comfortable talking about it, with the whole goal of honoring people's wishes and values and making sure their care is consistent with what they want.

Robert Espinoza: One of my favorite books on this topic is Being Mortal by Dr. Atul Gawande, and in it, he writes, “Scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by healthcare professionals.” He adds, “Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and deny them the basic comforts they most need.” How do you think modern medicine is helping people, and how do you think it's hurting them when it comes to death and dying?

Dr. Joseph Shega: So, modern medicine has come up with some amazing approaches to treatment that have transformed care for certain populations. Obviously, cancer is one that readily comes to mind where, when I trained at University of Pittsburgh, survival rates for many cancers like lung and colon were six to 12 months. And those survival rates have doubled, tripled, quadrupled with some of the innovations that have happened in tumor-directed therapy. So there's been some great advances.

But despite those advances, cancer is still the second most common cause of death in the United States. So even with those great innovations and prolongation of life and hopefully prolongation and quality of life, people still die from the same chronic illnesses they did 30 years ago: heart disease, cancer, lung disease, dementia. And so, despite those great advances and improvements in quality of life, people are still dying from those conditions.

And we need to continue to remind our partners that we appreciate all the advances that they're making, but at the same time, you have to have conversations about expectations and what the future will look like.

And I often like to use my dad as an example. He was diagnosed with metastatic colon cancer. I had very realistic conversations with him, my mom, and my siblings about what to expect. And at that time, the average life expectancy was two years. Having those conversations, he responded to first-line anti-tumor treatment, and he was on first-line anti-tumor treatment for 11 years. And now he's too sick to tolerate first-line treatment. And so now we talk about end of life more, and he himself made his decision to not be resuscitated the last time he was in the hospital, which surprised everybody but me. But everybody understood and accepted because we've had those conversations and, with each setback, what those setbacks meant.

So, it's just important to remember with those advances, we need to continue to recognize people who are dying from those conditions and continue to have those conversations when the natural history of the disease progresses, despite those treatments, what it means, and what the future will look like. And for everyone, hopefully, that future will be hospice care because it improves quality.

Robert Espinoza: One of the leading causes of death that has emerged in recent years is COVID-19. In fact, the data shows that as of June 2023, the COVID-19 pandemic has claimed more than 1.1 million lives in the U.S. and almost 7.7 million globally. Though some experts say that those figures are actually closer to 15 to 20 million.

What has this pandemic taught us about serious illness, death, and older people in particular?

Dr. Joseph Shega: I think it was a wake-up call for many that, at any time, we could transition from healthy to serious illness. And that at any time, we can become seriously ill and could impact and take our life. With that, what we've noticed is that more Americans seem to be open to talking about wishes and values in advanced care planning.

We did a survey that showed one in five respondents to the survey actually had loved ones who died from COVID, and they did not know their loved one’s wishes and values. And that was a wake-up call for them and an opportunity to start having those advanced care planning conversations.

Robert Espinoza: Joe, you graciously shared your story about your father. Are there any personal stories from your career that illustrate the complexity of dealing properly with death and dying?

Dr. Joseph Shega: So, that's a great question. I would say, in aggregate, what they have taught me is that what people want at the end of life is so individualized.

The most important thing to remember when we talk about end-of-life care is to create individualized plans of care and make sure that it's not a yes/no when people think about hospice but how can we meet them where they are, to help them transition and understand that they're suffering from life-limiting illness? And how can we focus on optimizing life and making life as good as it can be for however much time they may have left?

A perfect example was when we had a gentleman come to our inpatient unit. At VITAS, we're often the second, third, or fourth hospice people choose because people often have preferences, but the care they want isn't consistent with what that hospice was willing to provide.

So this was somebody who had had metastatic rectal cancer. He was in his 50s. He was married. He had kids that were teenagers. He had progressed through four lines of antitumor treatment. He had a large rectal abscess. He was bed-bound. He had just had a bilateral pulmonary embolism. He was very short of breath on oxygen, on three or four IV antibiotics, and completely deconditioned. And his goal was to try to get stronger and tolerate more antitumor therapy.

Everybody knew that was not possible. He had been turned down by an LTAC. He had been turned down by multiple skilled facilities. No home health provider would sign up for him. Two other hospices had said no because his goals weren't consistent with the care that they wanted to provide.

Clearly, there was a lot that needed to happen because when I saw him, his life expectancy was days to a week at most. But we were able to get him to the inpatient unit, continue the IV antibiotics, control his mixed nociceptive neuropathic pain from the infection invading and the tumor invading some of his nerves. And get him and his family to recognize that he was dying. And that we could honor his wishes in that he didn't die in the hospital. What that looked like may not be what he initially envisioned, but in the end, he had closure, his family had closure, and no doubt completely changed the bereavement for his wife and kids.

And so, how I started about creating those individualized care plans, right? End-of-life care isn't always perfect, but we do the best with what we have to help people understand what's happening to them and make sure that their wishes are honored.

Robert Espinoza: Joe, you mentioned the concept of hospice care earlier, and I find that people often confuse hospice care and palliative care. Can you help us understand—what are the key principles and goals of hospice care and palliative care and how are they different?

Dr. Joseph Shega: Yeah, that's a great question, and often, people confuse palliative care with hospice care. So, I like to think of it simply. Hospice care is palliative care in the last six months of life and is a defined benefit by Medicare. It covers medications, equipment, an interdisciplinary team, a physician, a nurse, a social worker, a chaplain, a volunteer, and a health hospice aid—all there to try to create a care plan to meet one's wishes, values, and goals. Decades of research show it helps improve quality of life while decreasing costs for the patient, the family, and the health care system.

Palliative care has been around more recently in the last 10 or 20 years. I think of palliative care as for people who have serious illnesses, but the prognosis is greater than six months. The challenge in the United States is it's not a defined benefit. So, if you've seen one palliative care program, you've seen one palliative care program, and the services that they offer are quite varied. Some may be a physician, some may be a social worker, and some may be a nurse. But what they provide is very different.

Most insurers don't have a defined palliative care benefit, or if they do, it's very limited. That just leads to a lot of confusion among families as well as healthcare clinicians because they don't understand the difference. Unfortunately, what's happened is so often now, healthcare professionals will refer to palliative care instead of hospice when people need hospice, and they're not matching the services with what they need. And so that's one gap that has widened, and my hope is that if CMS can come up with a palliative care benefit, it will help people with serious illnesses, pre-hospice, and then that transition to hospice to provide the best and end of life outcomes.

Robert Espinoza: You've hinted at some of this, but what are some specific barriers that patients and their families face when they access hospice care or palliative care services in this country?

Dr. Joseph Shega: Yeah, for hospice services in particular, one of the challenges is not all the services that they provide are the same. So, by law, all hospices must be 24/7, 365-coverage, meaning available any time, day or night, to support the patient and their family. They must include the core disciplines—physician, the nurse, social worker, chaplain, bereavement services, and volunteers. They have to pay for medications and equipment, but then, after that, hospices are very different in their philosophy and approach to care. Neither one is necessarily right or wrong, right? It's just how they envision the Medicare Hospice Benefit.

And so at VITAS, we're very open to things like antibiotics, IV fluids, tube feeding, high-flow oxygen—some of the more complex things that patients may need to support their end-of-life journey.

Whereas other hospices may not be as open to some of those treatments. It doesn't make it good or bad, but there's such variability in the type and approach to care. At the same time, CMS doesn't adjust for acuity and complexity when it looks at hospices, which leads to further confusion about what hospices can and can't do in the marketplace.

Robert Espinoza: In November 2022, ProPublica, an investigative media outlet, published an article that caused quite a stir within the hospice industry and the long-term care sector. This article shed light on the hospice care landscape, revealing how what was once a noble mission to offer dignified, end-of-life care had been tainted by lax regulations and profit-driven motives resulting in rampant fraud and exploitation.

Following this exposé, the four major hospice trade associations directed a memorandum to the Centers for Medicare and Medicaid Services, outlining 34 recommendations. These proposals advocated for more stringent regulations in areas such as ethical marketing practices, ownership transparency, comprehensive disclosure, and heightened scrutiny during the intake of initial patients, among other essential measures.

In light of these developments, I was interested to hear Joe's thoughts on where the hospice industry requires reform to restore its core values and ensure ethical, high-quality care.

Dr. Joseph Shega: So, while many people struggled with some of the things that the ProPublica article focused on, it did create this great synergy among the four organizations that you mentioned to step forward and lean into this is what we need as an industry to help ensure patients and families get consistent, high-quality end-of-life care. And so, to me, that's one of the big wins for an article that was very hard for some people to read when your whole life is focused on providing the best end-of-life care.

I think the common sense solutions focused more on newer hospices, making sure that they, in particular, meet the standards and policies set forth by CMS and ensuring that they're not able to be sold. People understand ownership is extremely important as a first step. Decades of research show hospices that have been around for over 10 years have superior quality and probably don't need as much focus as the newer hospices, ensuring that what the benefit was set out to do—improved quality—happens. I think that that approach makes sense, and the 34 measures put forth by the four organizations are a great first step.

Of course, there's a word of caution in that you don't want to overstep what should be done, which could lead to people being too cautious and not wanting to accept certain patients because of their acuity, complexity, or struggles with end-of-life care. And those patients and families may end up suffering an over-medicalized death, which would be a really bad outcome if there was too much over-regulation in how that looked.

But that's why the four groups set forth and leaned into what they think could improve hospices and make sure end-of-life care and the robustness of the benefits remain.

Robert Espinoza: You and I were on a planning committee focused on the serious illness workforce that was part of the National Academies of Sciences, Engineering, and Medicine.

How do we adequately prepare the entire workforce to meet the needs of people with serious illnesses?

Dr. Joseph Shega: So, the things that I focused on to help VITAS meet the workforce needs, not only of our organization but healthcare overall, are two main perspectives.

One is to be actively involved in the educational process of healthcare professionals. And so working with colleges, universities, and postgraduate education to be part of training the next generation of learners and leaders in health care is paramount. We have that opportunity to teach them, number one, what does interdisciplinary care mean? How does it change outcomes? Then, see the value of end-of-life care by better appreciating what an end-of-life care experience will look like.

The second is that so many high schools, colleges, universities, and even professional training require volunteer hours, and hospice is unique in that to be a Medicare-certified hospice, you must provide a certain amount of volunteer hours directed towards patient care. And so it creates this win-win opportunity where you can work with colleges, universities, and professional training schools to be the source where they can get their volunteer hours within hospice doing end-of-life care.

And so we've tried to create innovative programs for VITAS to support that—whether it's our VITAS individualized pampering program for patients to help define that individualized plan of care. Helping our volunteers work with patients and families to create life biographies. Most recently, we've been engaging with virtual reality and trying to leverage it to be a therapy that volunteers can provide for patients and families.

Getting volunteers involved from colleges, universities, and professional schools to understand end-of-life care but also to participate in that care to recognize the impact they can have.

Robert Espinoza: Joe, I want to get your thoughts about solutions to many of these problems and questions that you brought up. How can public policies and health care regulations be improved to enhance hospice care and palliative care services?

Dr. Joseph Shega: So, I think one of the main things when we look at policy and healthcare regulations is to recognize the research that's gone into establishing the Medicare Hospice Benefit. The Medicare Hospice Benefit was the first at-risk payment model for Medicare. Established in the 1980s, [this benefit] was passed into law under Ronald Reagan because it improved quality and saved money. It was the first value-based care model CMS had ever entered.

Despite that, patients continue to benefit from hospice services but for a very short period of time. The median length of stay in hospice remains around 18 days. That hasn't changed for decades. At the same time, only about 50 percent of Medicare beneficiaries ever benefit from hospice services. So that means half of patients who die that are older adults never receive hospice care.

So the real question is, how do we further integrate hospice into our healthcare system to encourage earlier access and greater access? Palliative care is part of that solution, as is continuing to double down on advanced care planning and the role of advanced care planning in understanding wishes, values, and goals.

And so I think those two things—investing in a palliative care benefit that's aligned to incentivize hospice utilization and, at the same time, increased advanced care planning and training the primary workforce in doing advanced care planning and having goals of care conversations.

And policies and regulations that encourage those things will provide a great solution to expanding the hospice benefit and improving end-of-life outcomes.

Robert Espinoza: It seems that our ability to pass these types of policies relies in many ways on our ability to discuss death and dying in ways that are productive and constructive for our families and our lives. How can we promote open and honest discussions about death and dying within our families, within communities, and within healthcare settings to foster a more compassionate and understanding approach?

Dr. Joseph Shega: So, it's a really interesting point you make in that there's so much fear and anxiety that comes with engaging in goals-of-care conversations and end-of-life discussions.

I mentioned earlier that one of the keys is to normalize it. When I had my geriatrics practice, I spent a lot of time in the memory disorders clinic—and so diagnosing many patients with neurodegenerative diseases that were progressive, not curable, and ultimately fatal.

As part of that process, the initial piece focused on diagnosis and treatment. And it just wasn't about disease-modifying therapy, which is very limited. But it was also about understanding what was important to people and taking the time when people had mild dementia to complete an advanced care plan. And then, along the journey, talk to families about the goalposts of decisions that will be coming up, what end of life will look like, and when hospice will be needed.

And so if we normalize that process as part of the care continuum, then there's less shock when it comes up when people are near the end of life. So, to me, the most powerful way is to encourage healthcare professionals to incorporate it as part of the disease management trajectory. Now, we're focusing on this. This is how we know disease will progress. Ultimately, it may become end of life. And when that happens, this is what we're going to do.

Robert Espinoza: Joe, let me ask you one final question. If you had all the power in the world, what would you change about our end-of-life care system?

Dr. Joseph Shega: If I had one wish about our end-of-life care system and how to make it better, it would be to get people to understand that end-of-life care is still about life.

We don't focus on death. Death is going to happen whether or not somebody enrolls in hospice. And studies show hospice care doesn't change life expectancy. One study showed you might live a little longer. Others show no difference. But in the end, end-of-life care is about life.

It's about embracing life. It's about making the best of whatever time we have left. And how do you want to spend that time? And then let's put a care plan together to try to make that happen.

If I could change one thing about our system, it would be to change the outlook about what hospice and end-of-life care is. To not make it about dying but to make it about living until death occurs.

Robert Espinoza: In early 2016, at age 39, I experienced a severe heart attack that nearly ended my life. One minute, I was walking near Prospect Park in Brooklyn, New York, and a week later, I was waking up in a hospital nearby from a weeklong coma. I was being told I had gone into cardiac arrest, and I was lucky to be alive.

My heart had stopped for a whopping 45 minutes, and an EMT had kept my brain functioning through CPR. Three weeks later, my heart surgeon told me I had a 6 percent chance of surviving at the time of the attack. I would spend much of that year coming in and out of hospitals and medical appointments, my brain fogged with uncertainty.

An expert in near-death experiences once told me that the two biggest questions facing people who go through these moments are: Why me and why did I survive? And what did I see when I went under, into that space near the beyond? In truth, I don't remember what I saw in those 45 minutes. And if I did, I erased it from my memory.

But what I've seen in the years after this near-death experience is a care field that struggles with its relationship to death and dying. Like many others, I routinely question where healthcare professionals, thanks to advances in medical technology, are crossing the line in keeping people alive beyond their preferences or even quality of life, which can vary from person to person.

Suppose we genuinely embrace our life as finite and our experience on this planet as microscopic, relative to the age of the universe. Would we embrace the here and now and take death and dying as a natural given? Would we transform our billion-dollar healthcare system and shift our national funding priorities from unnecessarily prolonging lives to creating an affordable, person-centered social safety net that embraces a natural life and death?

As for the question, why me? I'll never fully know the answer, but that might be the point. Because why not me? And regardless, isn't it a better use of energy to imagine a better life and death for all of us, irrespective of our circumstances?

Thank you to my guest, Dr. Joseph Shega, and to you, our listeners. If you enjoyed this episode of A Question of Care, please share it on your social channels and stay tuned for future episodes. This podcast was produced by me, Robert Espinoza, in partnership with Modry Media. Please make sure to rate and review the podcast wherever you're listening.

Advanced Lung Disease and COPD: Worse in Winter, but Hospice Can Help

Tue, 26 Dec 2023 05:00:00 -0500

By Henri Nammour, MD, Regional Medical Director, VITAS Healthcare

Winter has arrived, and with winter comes lower temperatures. The increased cold presents particular danger to people with advanced lung disease (ALD) in general and chronic obstructive pulmonary disease (COPD) in particular, leading to increased exacerbation frequency and worsening of symptoms.

With the chronic and life-limiting nature of these conditions, patients with ALD and COPD can benefit immensely from timely palliative care and hospice referral and involvement.

Decreased Temperatures, Increased Exacerbations

Evidence in the literature shows the seasonality of COPD exacerbations. A retrospective analysis of the large-scale TIOSPIR^® trial found “marked seasonal variation in COPD exacerbations, hospitalization, and mortality.” The authors note that “in the northern hemisphere, the peak for exacerbations is early winter, followed by the peak for hospitalizations in midwinter.”¹⁵ An analysis of numerous COPD-related studies worldwide saw a pattern of “clear seasonality in COPD [primary care] consultations” and “increased hospital admissions for COPD exacerbations.”⁸

As the temperature drops, the rate of COPD exacerbations increases. A study comparing meteorological variables with health system registry data showed an inverse correlation between temperature and COPD exacerbation rate.¹⁴

A Prevalent But Underdiagnosed Disease

In 2020, 12.5 million people reported a diagnosis of COPD, chronic bronchitis, or emphysema.⁶ COPD is the fifth disease-related cause of death.⁵ In 2019, there were close to 536,000 COPD hospitalizations and 1,320,000 COPD emergency department visits.⁴

These are staggering numbers, but COPD remains a disease with under-reported prevalence and potential underdiagnosis; according to the CDC, more than 50% of adults with low pulmonary function were not aware that they had COPD.²

With early diagnosis and proper use of advance care planning (ACP) and goals of care (GOC) discussion, the opportunity to involve palliative care early on in the disease course and hospice at the appropriate time can make a tremendous difference in ALD/COPD patients’ and their families’ and caregivers’ lives.

An Opportunity for Improvement

Hospice is underutilized in ALD/COPD patients. While more COPD patients are using hospice and palliative care, they are a small minority of this large patient population. A significant proportion of patients with COPD are not hospice users; consequently, they often receive a disproportionate amount of aggressive interventions at the end of life.¹³

While there has been a general trend of increased use of palliative care and hospice among COPD patients in the past two decades, “only a minority of patients with COPD die at home or in hospice. Early PC [palliative care] involvement in patients with severe COPD may improve the end-of-life experience and increase hospice use.”¹⁶ A greater proportion of decedents from pulmonary disease die in the hospital than individuals dying of cancer, cardiovascular disease, cerebrovascular disease, or dementia.⁷

For ALD/COPD patients, discussion of ACP and GOC are typically provided too late, if at all. They were less likely to have advance directives in place, leading to higher and more aggressive healthcare utilization near end-of-life that offers little benefit in the face of advanced disease.¹¹

What Patients Want

Patients with advanced respiratory illness want to learn more about end-of-life care. However, patients “report feeling frustrated by poor communication and discussion surrounding ACP, and often feel that important therapeutic and symptomatic goals are not discussed.”³

Notably and concerningly, fewer than one-third of patients with COPD and their caregivers had even heard of palliative care. Only a minority of these patients received formal palliative care referrals, and many are only referred after ICU admission or prior to hospice initiation.⁷

ACP happens rarely in advanced lung disease, with only about 20% of patients engaging in these conversations on average and almost 30% of these discussions occurring in the last three days of life.⁹ With timely and appropriate discussion of ACP and GOC, patients were less likely to receive unnecessarily intensive care towards end of life.¹¹

Hospice and Palliative Care Improve Clinical Outcomes

When asked about their goals and needs, patients with advanced illness desired controlling pain and symptoms, avoiding inappropriate prolongation of the dying process, having a sense of control, relieving burdens on family, and strengthening relationships with loved ones.

Greater utilization of hospice during the last 6 months of life is associated with improved patient experience and clinical outcomes.¹⁰ Patients with ALD and their families experience improved overall satisfaction with their care, improved symptom control and quality of life, fewer unnecessary procedures and interventions near the end of life and higher likelihood of dying at home. Earlier hospice referral has even been associated with prolonged survival.¹

Hospice Cost Savings: A Matter of Dollars and Sense

Per a recent report from NORC, hospice provides significant cost savings. The cost for Medicare beneficiaries who used hospice was lower than the cost for those who did not use hospice, with a 20% lower average total cost of care seen in beneficiaries with respiratory disease.¹²

NORC's findings show clear quantitative cost-saving benefit with the use of hospice in patients with respiratory diseases; however, the principal benefits of hospice remain the improvements in quality of life and in patient, family, and caregiver satisfaction.

Hospice Can Help

Hospice alleviates symptom burden and improves quality of life for patients suffering from ALD and COPD; it promotes goal-concordant care with decreased readmissions, reduced in-hospital mortality, lower total costs of care, and improvement in patient satisfaction.

If your patient does not yet qualify for hospice, bringing palliative care onboard early in the patient's disease course can help facilitate advance care planning and goals of care discussion, and ease a patient's transition into hospice when the time is right.

The prevalence of ALD in general and COPD in particular means that there is a large patient population that is not currently taking advantage of the myriad benefits that hospice can provide. There is ample opportunity for hospice to improve the quality of life for millions of patients and for their caregivers and loved ones.

1. Adler ED, Goldfinger JZ, Kalman J, Park ME, Meier DE. Palliative care in the treatment of advanced heart failure. Circulation. 2009;120(25):2597-2606. doi:10.1161/circulationaha.109.869123
2. Basics about COPD. Centers for Disease Control and Prevention. June 30, 2023. https://www.cdc.gov/copd/basics-about.html.
3. Brown CE, Jecker NS, Curtis JR. Inadequate palliative care in chronic lung disease. an issue of health care inequality. Annals of the American Thoracic Society. 2016;13(3):311-316. doi:10.1513/annalsats.201510-666ps
4. COPD trends brief - burden. COPD Trends Brief - Burden | American Lung Association. https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-burden.
5. COPD trends brief - mortality. COPD Trends Brief - Mortality | American Lung Association. https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-mortality.
6. COPD trends brief - prevalence. COPD Trends Brief - Prevalence | American Lung Association. https://www.lung.org/research/trends-in-lung-disease/copd-trends-brief/copd-prevalence.
7. Cross SH, Ely EW, Kavalieratos D, Tulsky JA, Warraich HJ. Place of death for individuals with chronic lung disease. Chest. 2020;158(2):670-680. doi:10.1016/j.chest.2020.02.062
8. Donaldson G, Wedzicha J. The causes and consequences of seasonal variation in COPD exacerbations. International Journal of Chronic Obstructive Pulmonary Disease. Published online 2014:1101. doi:10.2147/copd.s54475
9. Jabbarian LJ, Zwakman M, van der Heide A, et al. Advance care planning for patients with chronic respiratory diseases: A systematic review of preferences and practices. Thorax. 2017;73(3):222-230. doi:10.1136/thoraxjnl-2016-209806
10. Kleinpell R, Vasilevskis EE, Fogg L, Ely EW. Exploring the Association of Hospice Care on patient experience and outcomes of care. BMJ Supportive & Palliative Care. 2016;9(1). doi:10.1136/bmjspcare-2015-001001
11. Lee RY, Curtis JR, Kross EK. Physician orders for life-sustaining treatment and ICU admission near the end of life—reply. JAMA. 2020;324(6):608. doi:10.1001/jama.2020.8654
12. 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
13. Shen JJ, Ko E, Kim P, et al. Life-sustaining procedures, palliative care consultation, and do-not resuscitate status in dying patients with COPD in US hospitals. Journal of Palliative Care. 2018;33(3):159-166. doi:10.1177/0825859718777375
14. Tseng C-M, Chen Y-T, Ou S-M, et al. The effect of cold temperature on increased exacerbation of chronic obstructive pulmonary disease: A nationwide study. PLoS ONE. 2013;8(3). doi:10.1371/journal.pone.0057066
15. Wise RA, Calverley PM, Carter K, Clerisme-Beaty E, Metzdorf N, Anzueto A. Seasonal variations in exacerbations and deaths in patients with COPD during the TIOSPIR® trial. International Journal of Chronic Obstructive Pulmonary Disease. 2018;Volume 13:605-616. doi:10.2147/copd.s148393
16. Yaqoob ZJ, Al-Kindi SG, Zein JG. Trends and disparities in hospice use among patients dying of COPD in the United States. Chest. 2017;151(5):1183-1184. doi:10.1016/j.chest.2017.02.030

Bringing Veteran Patients Peace Near the End of Life with Advanced PTSD Therapies

Mon, 27 Nov 2023 05:00:00 -0500

The Benefits of Hospice Care

For veterans nearing the end of life, hospice care offers 24/7 access to clinical and psychosocial support. Whether through nurses, social workers, chaplains, or volunteers, hospice care ensures that veterans receive the personal attention and support they need. In many cases, veteran-to-veteran volunteers can offer a unique level of understanding and companionship.

Hospice care, being an intimate form of care, allows providers to identify and address emotional and psychological needs, which are especially crucial for veterans. This level of personalized care ensures that veterans receive the comfort and support they deserve as they face the end of life.

Tips for Healthcare Professionals Caring for Veteran Patients With PTSD

To ensure veterans access VA benefits and hospice services effectively, it is crucial for healthcare professionals to understand the unique needs of veterans, especially those with PTSD.

Additionally, understanding the steps for veterans to access VA benefits is vital. Veterans should enroll in the VA Healthcare system by visiting VA.gov or calling 877-222-8387 and selecting option #1. Healthcare professionals can assist in this process and guide veterans to their state veteran service organizations for additional support.

The evolving landscape of PTSD therapy and the growing focus on moral injury underscore the importance of providing holistic and veteran-specific care to our nation’s heroes. With compassion, innovation, and commitment, we can help veterans lead lives marked by purpose, meaning, and, ultimately, peace.

Clinicians with veteran patients facing PTSD should consider a hospice provider who approaches veteran care by looking at the entire journey of every individual’s life. Factors such as the war or conflict they served in, their age when they volunteered or were drafted, and their rank provide insight into the best ways to approach caring for each patient. By asking the right questions and fostering compassionate communication, we can better understand the needs of veterans, especially those with PTSD, and provide tailored care.

¹Kaiser, et al. (2023). Factors Associated With Distress Related to Posttraumatic Stress Disorder at the End of Life Among US Veterans. Journal of Pain and Symptom Management.

²O’Haire, M. E., Guérin, N. A., & Kirkham, A. C. (2015). Animal-assisted intervention for trauma: A systematic literature review. Frontiers in Psychology, 6.

Partnering to Keep Hospice Patients Out of the Hospital

Wed, 27 Sep 2023 04:00:00 -0400

Hospice patients and their family members typically call 9‑1‑1 because they are symptomatic, frightened, or alone—not because they want to go back into the hospital. Most of the time, they are simply searching for additional support.

EMS teams recognize this. Seriously ill patients or their families are among those who call 9‑1‑1 most often. These “frequent runs”:

Do not benefit the patient
Put undue pressure on first responders
Contribute to overcrowding of busy emergency departments
Result in unnecessary hospitalizations

Because the role of hospice is to ensure in-home support and the most appropriate care possible for patients and families coping with serious illness, collaboration between hospice and EMS benefits everyone. A proactive meeting of the patient, family, EMS, and hospice professional gives everyone an opportunity to assess the situation and get to know one another. That ensures the patient gets the care they need, the caregiver’s fears are allayed, and the EMS is fully informed if they get a call from this address.

VITAS Readmission Prevention Program

An example of this working partnership between hospice and EMS is the collaboration between VITAS Healthcare and Acadian Ambulance Service in Texas. According to Joe Brickner, Vice President of Operations for VITAS in Texas and Kansas, the Readmission Protection Program “allows us to give a higher level of care to our patients and achieve a better level of satisfaction for the patient and family.”

VITAS flags the charts of patients most at risk of going back into the hospital. This determination usually happens at admission, when the patient’s hospice team meets to discuss the physical, emotional, and spiritual needs of the patient and family. Factors include:

Is the patient full code (no Do Not Resuscitate order in place)?
Does the patient have a history of going to the ED? Do they verbalize a desire to call 9‑1‑1?
Does the patient live alone?
Does the patient or primary caregiver have a high level of anxiety?
Is this the first time the patient is in a nursing home or assisted living facility following hospitalization?
Has pain management delivery transitioned from intravenous to oral?
Does the physician indicate the patient and/or family are struggling with acceptance of the terminal prognosis?

Patients designated high risk receive an introductory visit by the ambulance service’s VITAS-trained paramedics and additional visits and calls from members of their hospice team, including the physician, nurse, hospice aide, social worker, chaplain, and volunteer.

High-risk patients and caregivers are instructed to call Telecare, the VITAS telephone triage system, rather than 9‑1‑1 if they need help. They wear a medical alert system synced with EMS that is activated by the push of a button. When called, Acadian contacts a Telecare clinician, who calls the patient, assesses the situation, and sends the Acadian paramedic, VITAS nurse, and other hospice team members to the patient’s bedside, according to their need.

Under the direction of the VITAS team physician, paramedics are authorized to administer appropriate medications, start IVs, give oxygen, and provide nebulizer treatments and other interventions as needed.

The VITAS nurse determines if the patient’s condition warrants increased visits from the hospice team, Intensive Comfort Care^®, or inpatient care. Intensive Comfort Care provides shifts of continuous care in the home until the issue is improved. For severe symptoms that need more specialized or RN care, the paramedics transport the patient to a local VITAS inpatient hospice unit. All of these choices avoid hospital or ED admission.

Meeting the Needs of a Changing Healthcare Marketplace

Partnerships such as the one between VITAS and Acadian Ambulance benefit hospitals, physician groups, insurers, and other healthcare providers by lengthening the patient’s continuum of care.

“This type of program supports the changes in the marketplace and goals of our healthcare partners to keep patients in the most cost-effective setting that aligns with their goals and needs,” explains Brickner. “In the first week of the program, we were able to keep six patients home, preventing them from having to go to the hospital.”

For the patients and families involved in collaborations like this one, the biggest benefit is knowing they are never alone and have the backup support to stay where they really want to be—home.

This article was originally published in October 2016 and updated in September 2023.

Overcoming Barriers to Hospice Care for Advanced Cancer Patients

Thu, 03 Aug 2023 04:00:00 -0400

By Ileana Leyva, MD, Regional Medical Director, VITAS Healthcare

When a patient's advanced cancer no longer responds to curative treatments, they arrive at a critical point in their healthcare journey.

A knowledge gap exists surrounding indicators of poorer prognosis in patients with serious illness, a gap that contributes to missed opportunities for hospice services and significant delays in access for those who are referred to hospice care.

In one study, palliative care (PC) experts correctly projected prognosis for only slightly more than 40% of patients with advanced cancer.¹ Previous studies among non-PC clinicians report accuracy rates between 20%-30% in similar patient populations.^2,3 When clinicians overestimate survival, patients are substantially less likely to enroll in hospice at all and more likely to enroll too late to benefit from its services.²

Patients and their families might avoid acknowledging the terminal nature of the condition; they may also receive poorer communication from their physicians because of a lack of training in facilitating productive goals-of-care conversations.

These barriers can delay goal-concordant care that improves quality of life near the end of life.

Barriers to Hospice Care Persist for Cancer Patients

Hospice use among patients with advanced cancer is associated with reduced pain intensity, symptom burden, and psychological distress; improved quality of life; decreased usage of non-beneficial aggressive care; and increased likelihood of death in a location of preference (most often at home).^{7, 8-10}Evidence also demonstrates that hospice use decreases the frequency of non-beneficial hospitalization and invasive procedures.⁷

In addition, a propensity-score-match sample of 1,970 family members of patients with advanced cancer who enrolled in hospice reported better outcomes than their non-hospice counterparts. These outcomes included excellent quality end-of-life care (57% hospice vs. 42% non-hospice), end-of–life wishes were followed a great deal (80% vs. 74%), and death occurred in a patient’s preferred setting (68% vs. 39%).⁴

Despite these outcomes, research has identified several reasons that palliative and hospice care services may be underutilized by patients with advanced cancer, including:

Reluctance to acknowledge illness severity⁵
Perceived understanding of hospice as relinquishing hope⁵
Socio-demographic variables including age, gender, race, particularly for racial minorities (Black, Asian, Pacific Islanders), low socio-economic condition, and rural residence⁶
Clinician-related barriers, including difficulties with communication and not being informed about available care choices⁶
Clinicians’ challenges in determining patient eligibility for hospice⁵

Clinicians can help overcome these barriers in several ways:

Fully communicate the prognosis and disease trajectory.
- Being matter-of-fact about their condition gives the patient the benefit of realistic expectations, allowing for pragmatic planning.
Set aside time to conduct a goals-of-care conversation.
- Studies show goals of care conversations are associated with improved end-of-life outcomes for the patient and their family, including goal-concordant care for the patient and reduced anxiety and depression for surviving family members.¹¹
- Ensure the end-of-life wishes of patients and families are met by making sure they have time to be heard, while confirming that you understand each concern. Using an approach that empathizes, informs, and seeks to learn about the patient’s healthcare goals often results in the patient working with you to develop their preferred care plan.
- Dedicate adequate time during a visit to focus solely on goals-of-care planning.
- Use silence strategically, giving the patient and family time to process complex emotions.
Educate the patient and their loved ones about their options.
- Patients and families need to clearly understand the full scope of care options to make informed decisions. No loved one should be left saying, “I wish I had known.”
- Take time to help them understand which options best support the patient’s goals and wishes.
Listen and speak on their terms.
- A person’s faith background, cultural traditions, religious values, and socioeconomic status can shape their views on end-of-life care. When discussing options, make the conversation more productive by being mindful of the cultural, generational, and personal beliefs involved.
- Be aware of language barriers that can lead patients to feel misled or inadequately treated. Work through these for clarity so patients clearly understand what hospice is and where they receive care.
- Religious and cultural traditions can impact pain management at the end of life. Palliation of pain and symptoms is a top care priority for many patients and families; others view physical suffering as simply a part of life. Consider asking the simple question: “What does comfort mean to you or your loved one?”
- Approach cultural barriers by discerning who makes the life-changing decisions in the family. Pause before providing unsolicited advice.

Why Sooner Is Better for Hospice-Eligible Patients

In most cases, patients with cancer are not referred to hospice until they have only a few days left to live.¹⁰ From 2016-2018, nearly 38% of all hospice patients received care for less than two weeks, depriving them of the full advantages of the Medicare Hospice Benefit.¹²

Early utilization of palliative care is associated with symptom relief, improved mood, reduced depressive symptoms, improved quality of life and survival, overall satisfaction with treatment outcomes, and reduced cost of care.⁶ The reduction in costs when patients across all disease classes, including cancer, use hospice can be significant. Medicare beneficiaries with cancer who used hospice for 31-60 days had a difference of 6% compared with beneficiaries who did not use hospice. For those cancer patients with longer hospice stays, the difference increased further: 61-90 days 9% less, and 90-180 days 13% less.¹⁴

Patients and their loved ones benefit together when early referral guides them to symptom-based care plans and specialized end-of-life services; likewise, they experience less satisfactory outcomes together when such care is delayed.

When Quality of Life Is the Optimal Choice: Referring to Hospice

For hospice-eligible patients, an interdisciplinary team of hospice care experts can provide clinical and psychosocial services to increase a patient’s quality of life by expertly managing their symptoms while they remain in their home or other care setting of choice.

Consider hospice care if your patient with advanced cancer has:

Progressed through first-line treatment and spends 50% of waking hours in a bed or chair
An average life expectancy of ≤ 3 months
Indicated they are no longer interested in pursuing anti-tumor therapies

What Can VITAS Offer Your Patients Living With Advanced Cancer?

To provide quality care to your patients, VITAS offers advanced illness specialists who manage pain and symptoms, including high-acuity care to optimize function and quality of life, along with:

Care coordination
Open formulary
HME and supplies
24/7/365 clinical care support
Complex modalities
Integrative therapies
Bereavement services

Check with VITAS to determine your patient’s eligibility. VITAS is available 24/7 for seamless care transitions.

¹ Gramling, R., et al. (2019). Palliative care clinician overestimation of survival in advanced cancer: disparities and association with end-of-life care. Journal of Pain and Symptom Management, 57(2), 233-240.

² Glare, P., et al. (2003). A systematic review of physicians’ survival predictions in terminally ill cancer patients. British Medical Journal, 327(7408), 195.

³ Hui, D. (2015). Prognostication of survival in patients with advanced cancer: predicting the unpredictable? Cancer Control, 22(4), 489-497.

⁴ Kumar, P., et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432.

⁵ Pate MN, Nicolla JM, Friedman, FAP, et al: Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions. American Society of Clinical Oncology JCO Oncology Practice. 16 (12): 803-808, 2020.

⁶ Parajuli, J, Tark, A, et al: Barriers to palliative and hospice care utilization in older adults with cancer: A systemic review. J of Geriatric Oncology. 11: 8-16, 2020.

⁷ Finnigan-Fox G, Matlock DD, Tate CE, et al: Hospice, she yelped: Examining the quantity and quality of decision support available to patients and families considering hospice. J Pain Symptom Manage 54:916-921.e1, 2017.

⁸ Wright AA, Zhang B, Ray A, et al: Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA 300:1665-1673, 2008 22.

⁹ Trevino KM, Prigerson HG, Shen MJ, et al: Association between advanced cancer patient-caregiver agreement regarding prognosis and hospice enrollment. Cancer 125:3259-3265, 2019.

¹⁰ Waldrop DP, Meeker MA, Kutner JS: Is it the difference a day makes? Bereaved caregivers’ perceptions of short hospice enrollment. J Pain Symptom Manage 52:187-195.e1, 2016.

¹¹ Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: Randomised controlled trial. BMJ, 340(mar23 1), c1345–c1345. https://doi.org/10.1136/bmj.c1345

¹² National Hospice and Palliative Care Organization. (2020). NHPCO facts and figures: Hospice Care in America.

¹³ Wittenberg-Lyles EM, Sanchez-Reilly S. Palliative care for elderly patients with advanced cancer; a long-term intervention for end-of-life care. Patients Educ Couns 2008:71; 351-5.

¹⁴ NORC at the University of Chicago. Retrieved from Value_Hospice_in_Medicare.pdf (nhpco.org)

The Qualitative and Quantitative Value of Hospice in Medicare

Mon, 03 Apr 2023 04:00:00 -0400

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

As a fundamentally patient-and-family-centered care model, hospice provides patients with improved clinical outcomes, improved pain control, reduced physical and emotional distress, and the ability to spend their last days at home, among loved ones.

A new report from NORC at the University of Chicago (NORC) found that greater utilization of hospice during the last six months of life is associated with increased satisfaction and quality of life, while also reducing Medicare costs—$3.5 billion in savings in one year.

The Unparalleled Value of Hospice

Hospice uniquely provides a person- and family-centered care model. With hospice, patients are at the center of the care continuum. They can spend their last months, weeks, and days of life at home surrounded by loved ones. Enrollees in hospice report overall better quality of life, while experiencing fewer burdensome care transitions.

By investing in serious illness care, we are also able to increase the quality of end-of-life care.

Hospice care entails foregoing continued curative treatments, with care instead focusing on aggressive interventions, treatments, and services to manage symptom severity, reduce pain, and manage the terminal illness and related conditions in the setting of choice—wherever the person calls home. Patients using hospice benefit from holistic care provided by an interdisciplinary team that works together to address their physical, psychological, social, and spiritual needs.

While the holistic and qualitative benefits of hospice are immeasurable, there are quantifiable benefits as well. The NORC study shows that over the last 12 months of life, as hospice use increases, total spending decreases relative to non-hospice. The reduction in costs when patients across all disease classes use hospice can be significant, up to 25% in Medicare beneficiaries with CKD/ESRD who used hospice.

Notably, in the last year of life, hospice usage reduces the total costs of care for Medicare by an estimated $3.5 billion a year.

Avoiding Unwanted, Burdensome Treatments

Hospice helps patients avoid burdensome, unhelpful, and potentially harmful treatments at end of life that may require continued and repeated hospitalizations and emergency department visits. These interventions often result in over-medicalized care that contributes to discomfort, functional decline, and increased costs, without prolonging life.

Healthcare professionals should initiate compassionate conversations early on in the care process with patients and families to share information and educate them on the nature of the hospice benefit and what it entails, to ensure that their end-of-life needs and wishes are met.

If a patient is hospice-eligible, early discussion and a timely referral are paramount.

Resource: Hospice eligibility guidelines >

Longer Stays: The Key to Maximizing the Benefits of Hospice

Earlier enrollment and longer lengths of stay help patients maximize the benefits of hospice. Many Medicare beneficiaries do not use hospice at all or use it for a very short period of time. These short lengths of stay, while still beneficial compared to not receiving hospice at all, are not long enough to reap full benefits of the holistic care model.

Hospice care improves patient outcomes—better symptom relief, goal attainment, and quality of life—with longer hospice stays experiencing the highest quality of life outcomes. NORC’s analysis found that Medicare spending in the 12 months preceding death is consistently lower for beneficiaries with lengths of stay of 15 days or more, and total Medicare spending for hospice patients with a length of stay of 6 months is lower than non-hospice decedents which continues for at least up to one year.

Raising awareness, informing, and educating patients and families about the hospice benefit and expanding earlier access will improve quality of life and care for millions of beneficiaries.

In addition to meeting the unique needs of patients, hospice care affords improved outcomes for family members, as well. Families benefit from education around the natural history of terminal illness, so that they know better what to expect and how to manage it. Individualized care plans include regular visits by the interdisciplinary team being adjusted by need with availability of 24/7 in-person after-hours support.

Family members of hospice patients compared to non-patients experience better emotional outcomes with less depression, anxiety, and burden, along with improved quality of life.

Improving Quality of Care and Quality of Life—for Patients and Families

Hospice improves the quality of care and quality of life of patients with many different terminal diseases, while supporting the needs and well-being of their family members. From increased satisfaction and quality of life, to improved pain control, to reduced physical and emotional distress, and reduced prolonged grief and other emotional distress, hospice offers multiple benefits to patients, families, and caregivers.

Many families often say, “We only wish we had chosen hospice earlier.”

Where VITAS Stands

At VITAS Healthcare, we understand the many ways that hospice improves quality of life for Medicare beneficiaries, and we are now glad to see that this proven framework also saves tax dollars. We support expanding earlier access to hospice care, across the most common causes of death in the US—heart disease, cancer, lung disease and dementia—which can greatly benefit from high-quality end-of-life care.

All hospice-eligible patients should have the opportunity to access hospice in a way—and for a length of time—that allows them to fully benefit from this unique care model.

By investing in serious illness care, we are also able to increase the quality of end-of-life care for millions of patients, families, and caregivers across the country.

Pain Management for Patients Near End of Life

Wed, 01 Mar 2023 05:00:00 -0500

By Aaron Ismaili, MD, Regional Medical Director, VITAS Healthcare

The natural history of many illnesses results in the development of physical and psychological symptoms, with pain often occurring the most commonly as end of life approaches.

A complex, feared, and often undertreated symptom, pain can diminish quality of life, cause undue stress, and affect day-to-day activities. Pain is a serious issue for as much as 40% of the population¹, and about 25% of the elderly do not receive adequate analgesia.

For healthcare professionals caring for patients nearing end of life, understanding the multifaceted nature of pain management, as well as a thorough assessment of the burden and benefits of each medication, is integral to providing comfort when patients need it most.

A Diverse Multimodal Approach

Appropriate pain management is an important component of the care plan for patients with life-limiting illnesses. As pain is not a monolithic entity but rather a complex syndrome that differs with every patient that experiences it, it requires a diverse, multimodal approach, one that hospice can provide.

A wide variety of services must be provided to ensure appropriate pain management. To this end, VITAS offers the following:

Thorough pain assessments at each visit
Adjustments of medication and dosages based on a patient’s pain level
Pain experts who choose the most appropriate, least invasive route toward relief
Training for patients, family members, and caregivers on the administration of pain medications
Information about a patient’s disease process and its signs of progression
Breathing and relaxation techniques to help patients cope with symptoms
Massage, music therapy, and other integrative services, as available
Around-the-clock access to clinical teams
Training for clinical staff and patient caregivers to recognize and address side effects of pain medication

The pain management process requires physicians to remain cognizant of the goals of care as determined through open communication with the patient and family, while recommending the most effective and appropriate medications and therapies needed to mitigate the pain.

A Person-Centered Team Effort

Teamwork is vital for effective pain management. As the nature of pain extends beyond the physical and encompasses the psychological, social, and spiritual domains, pain management must address all of these needs. This complex task requires a team effort.

With the multifaceted nature of pain in mind, hospice team members partner with the patient’s primary care clinicians to address symptoms such as pain.

At VITAS, our pharmacotherapy approach leverages the diverse skill sets of an interdisciplinary team to help manage patients with complex needs. Hospice teams comprise:

Physicians who work with the patient, caregiver, and primary care clinician to address symptoms such as pain
Registered nurses who are skilled in caregiver education and managing pain and other symptoms
Social workers who provide emotional support and help with financial concerns and planning
Hospice aides who provide personal care (bathing, dressing, feeding, etc.) based on each patient’s plan of care
Chaplains who work with the patient’s own clergy and offer spiritual support
Volunteers trained by VITAS to provide companionship, pampering, life enrichment, and respite relief for caregivers
Bereavement specialists who offer grief and loss support and help with memorial services and other care for loved ones

Together, these team members all work towards the same goal: to effectively manage a patient's pain and other symptoms and to prevent further suffering, while maximizing quality of life in keeping with the patient's and family's wishes regarding goals of care.

VITAS hospice team members work with patients in their preferred setting of care; at home, in one of our dedicated inpatient hospice units, in a hospital, nursing home, assisted living community, or other residential care facility.

If your patient with advanced illness is experiencing pain, find out if they may be hospice eligible by using our interactive Palliative Performance Scale.

¹Zelaya, et al. (2020), Chronic Pain and High-Impact Chronic Pain Among U.S. Adults, 2016. NCHS Data Brief No. 390. Available at https://www.cdc.gov/mmwr/volumes/67/wr/mm6736a2.htm

As Deaths Increase During the Holidays, Consider Hospice for Patients with Advanced Disease

Wed, 07 Dec 2022 05:00:00 -0500

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

The holiday season evokes images of family gatherings, gift exchanges, and twinkling lights. In the warm glow of festivities, few associate it with an increase in death.

Yet, a study in Social Science & Medicine points out, "for all settings combined, there are holiday spikes for most major disease groups and for all demographic groups, except children. In the two weeks starting with Christmas, there is an excess of 42,325 deaths from natural causes above and beyond the normal winter increase. Christmas and New Year’s appear to be risk factors for deaths from many diseases."¹

Patients who are in the advanced stages of illness are likely more susceptible to further decline during this season. Amid the holiday hustle, clinicians can support family members by anticipating their patients’ needs. For some, hospice services offer next-level clinical care to manage their pain and symptoms and provide multidisciplinary resources.

To supply these services, VITAS hospice teams include a physician, nurse, hospice aide, social worker, chaplain, volunteer, and bereavement specialist. These experts work together to support both the patient and the family.

Importantly, hospice services are provided wherever your patient calls home, be it a private residence, assisted living facility, skilled nursing facility, or elsewhere. This enables people near the end of life to spend this special time of the year with loved ones in an environment they prefer.

Hospice Support for Patients With Advanced Illnesses

Assessing hospice eligibility sooner rather than later is especially helpful during the holidays. Consider that more than one-third of patients live less than seven days in hospice. This means too many patients miss months of care and support which would have enhanced their quality of life near the end of life.

Nothing matters more than the intimate knowledge of individual patient care.

As hospital and long-term care professionals take time off, VITAS hospice care remains available 24/7, 365 days a year, including holidays. This accessibility allows patients with serious illnesses to get consistent quality care from a team of providers.

Laura C., a patient’s loved one from Brevard County, Florida, explains how VITAS has worked for her: “You are assigned to a specific team of real people, in real time, who really know you, your history, your specific care plan, and your wishes any time of the day or night, weekend or weekday, or holiday,” Laura says. “Nothing matters more than the intimate knowledge of individual patient care."

A personalized care plan, coordinated by hospice experts, makes the transition between practitioners in the continuum of care seamless. Our 24/7 availability also helps your patients avoid rehospitalization and stay out of the ED. This, in turn, keeps patients in their preferred setting while the hospital’s quality metrics remain high, reducing lengths of stay and readmission rates.

Assessing Patient Eligibility

What makes a patient with a serious illness hospice-eligible? Consider the following guidelines:

The patient’s illness is terminal (a prognosis of ≤ 6 months) and the patient and/or family has elected palliative care.
The patient has a declining functional status as determined by either:
- Palliative Performance Scale (PPS) rating of ≤ 50%-60%
- Dependence in 3 of 6 Activities of Daily Living (ADLs)
The patient has an alteration in nutritional status, e.g., > 10% loss of body weight over last 4-6 months
The patient has an observable and documented deterioration in overall clinical condition in the past 4-6 months, as manifested by at least one of the following:
- ≥ 3 hospitalizations or ED visits
- Decrease in tolerance to physical activity
- Decrease in cognitive ability
Other comorbid conditions

These guidelines are a reference—not a replacement—for a physician’s professional judgment. By law, healthcare professionals must certify that patients meet guidelines to be eligible for a referral to a hospice provider.

If a patient meets the guidelines, timely identification increases the likelihood that the patient and their families will benefit from compassionate, end-of-life care.

Offering Support to Loved Ones as They Cope With Death During the Holidays

If a patient dies, the holidays may heighten the sense of grief and loss for loved ones. Offer support to them by:

Being present for the family—No matter how you or your staff are feeling, they have lost a loved one.
Educate those who are mourning to give themselves permission to grieve in their own way.
Write a personal note to the family.
Consider attending the funeral—This will be based on the closeness of the relationship with the patient and the family. Some professionals find closure from the process. Families appreciate your presence.

When a Patient Dies in Hospice

Each hospice team includes a chaplain and a bereavement specialist. The chaplain provides pastoral care, including listening, talking, sharing stories, and asking questions. They also reassure, comfort, pray, or read inspirational materials. The chaplain can arrange any support necessary to help navigate non-medical issues and challenges.

The bereavement specialist addresses both anticipatory grief and loss after death. Hospice families receive bereavement support up to 13 months after a death, including consistent contact, support groups, grief education and one-on-one visits.

Here for the Holidays

VITAS knows that the holidays are a sensitive time of year to experience loss. We are here to support healthcare practitioners, patients with serious illness, and their families. To determine if your patient is hospice eligible, use our PPS calculator here.

¹Source: Phillips, D., Barker, G., et al: Christmas and New Year’s as Rick Factors for Death. Social Science & Medicine, 71 (8), 2010.

Providing Specialized Care for Vietnam Veterans

Fri, 11 Nov 2022 05:00:00 -0500

By Faith Protsman, MD, Regional Medical Director, VITAS Healthcare

Vietnam War veterans face unique obstacles throughout the twilight of advanced illness. For hospice care providers to tailor care to meet the needs of veterans who have served in this theater of war, they must consider the tribulations these patients face as they reach the end of their lives.

The Vietnam War era was a very tumultuous time to be a soldier. The United States' prolonged involvement in a war of questionable motivation left society with disdain toward the government and its institutions, especially the military.

Coupled with horrific images shown on television, constant controversy was a new reality and negative public opinion formed around this conflict, of which those serving the nation were not spared.

Careful consideration is necessary when treating patients facing these traumas.

Tours of duty proved to be traumatizing in many ways. Young soldiers, some having just turned 18, were drafted into a war that many of them did not believe in. They were not fighting for love of country and God; rather, they were fighting for survival and out of fear for their lives.

Intimate battles in the dense jungle led many to be subjected to the horrors that come with fighting in a foreign land that was only familiar to the elusive guerilla enemy soldiers.

Servicemembers did not receive a warm welcome when returning home from Vietnam, often being judged and labeled as cruel and even inhumane.

Moral Injury Can Impair Mental Health

This “perfect storm” of trauma led to lasting moral injury that plagues many veterans for their entire lives. Veterans returning from the war were marginalized and pushed into isolation, often turning to alcohol and substance abuse, which worsened their anxiety and exacerbated their strife.

Questions like “I’ve never spoken about the war, can I now?” “Was the war moral or immoral?” and “Was I a good soldier?” come bubbling to the surface later in life as their illnesses intensify and their defenses weaken.

Careful consideration is necessary when treating patients facing these traumas.

The restlessness that can result from post-traumatic stress disorder (PTSD) is often treated with benzodiazepines. In most cases, these medications can bring relief through calming the patient.

Yet, there is a common trend amongst veterans who cope with trauma that results in the opposite effect.

Benzodiazepines can lower the walls that Vietnam veterans have built up throughout a lifetime of suppressing trauma and negative memories. This class of medications can exacerbate the symptoms of PTSD as traumatic experiences and feelings of regret resurface. Benzodiazepine-induced inhibition of neurotransmission can even lead to agitated toxic psychosis, increased anxiety, hostility, and rage.¹

The Value of Compassion Along with Clinical Care

Remaining considerate does not end with simply staying mindful during the planning of clinical solutions. Providing care for Vietnam veterans requires a high level of empathy.

A key to an empathetic approach is taking the time to listen nonjudgmentally. Though seemingly simple, practicing nonjudgmental, open communication with patients facing trauma from war can help avoid the all-too typical responses of “It’s okay” and “You did what you had to do.”

These patients do not need sympathy, because they have been judged enough throughout their lives. When care teams approach them without judgment, they honor the sacrifices these heroes have made.

VITAS hospice care provides compassionate care approaches that are tailored to meet the distinctive needs of Vietnam veterans. With the Veterans Administration (VA) offering hospice care as part of its medical package, VITAS team members can provide empathetic psychosocial support, while utilizing clinical solutions that help manage symptoms.

The qualifications for veterans to receive hospice benefits include:

A life-limiting illness
Treatment goals that focus on comfort, rather than curative treatments
A life expectancy of 6 months or less, if their illness runs its normal course

Veterans also benefit from the option to receive concurrent care through the VA. The VA can provide curative treatments as the patient simultaneously receives symptom-managing comfort care administered by the hospice care provider of their choosing.

Offering solace, while remaining compassionate when patients need it most, is too often overlooked in the busy practice of healthcare. Acknowledging the adversity that Vietnam War veterans have had to face throughout their lifetimes and adapting care approaches to meet their needs is the best way for healthcare providers to give back to those who have sacrificed so much for the preservation of freedom.

¹Paton, C. (2018, January 2). Benzodiazepines and disinhibition: A review: Psychiatric bulletin. Cambridge Core. Retrieved November 2, 2022, from https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6

Goals-of-Care Conversations Empower Practitioners to Initiate Vital Discussions

Tue, 16 Aug 2022 04:00:00 -0400

Goals-of-care conversations, including end-of-life discussions, improve patient and family outcomes. Yet, an overwhelming majority of clinicians do not report feeling comfortable “having the hospice discussion.”

VITAS' Goals-of-Care Preceptorship Program was created to help assuage this reluctance.

“Having difficult conversations is never easy, and many clinicians do not have the training to approach these, making it a barrier to getting started,” explains VITAS Chief Medical Officer Dr. Joseph Shega. “Also, clinicians fear ‘hurting’ patients and families with information. Naturally, they want to protect them even though it may inadvertently be more hurtful than helpful.”

What Happens When Patients Do Not Know Their Options

Without having goals-of-care conversations, patients and families endure over-medicalized care in the last months of life. This can include increased ED visits, hospitalizations with ICU stays, skilled care, and procedures and other diagnostic tests which reduce quality of life. These also increase healthcare and patient and family costs—and do not prolong life.

“If no one talks about what is actually happening, patients end up being in and out of the hospital and skilled facilities and receiving care that is not consistent with their wishes and values,” says Dr. Shega.

The goals-of-care conversation prompts an insightful reflection on what constitutes a meaningful end-of-life process.

“Patients and families can identify what is important to them. Having these conversations helps ensure their care matches their wishes,” explains Dr. Shega. “The most common values at the end of life are to be at home and out of the hospital, get good pain and symptoms control, further relationships with loved ones, and not be a burden.”

Timely Transitions in the Continuum of Care

When patients who are seriously ill have passed the threshold of being able to receive curative treatment, their quality of life in their remaining weeks and months becomes a priority. Accessing the full benefits of hospice care enables them to receive clinical, emotional, and spiritual support. The sooner they gain access to these care resources, the better equipped they are for this end-of-life journey.

The three pillars to facilitate timely transitions to hospice are:

Understand the benefits that come with hospice services
Be able to identify when someone with serious illness has a life expectancy of six months or less
Incorporate essential communication skills and a structured framework to have a goals-of-care conversation

Making the Conversation Easier: Goals-of-Care Preceptorship Program

VITAS created the Goals-of-Care Preceptorship Program in 2022 to increase the comfort of healthcare clinicians in initiating these vital conversations with patients. Leveraging evidence-based data, this certificate program helps physicians, nurse practitioners, advanced practice nurses, and physician assistants approach goals-of-care conversations with confidence.

Members of the Volusia Flagler Advanced Practice Nursing Council participate in a VITAS Goals of Care Preceptorship program in March 2024.

“We often hear: ‘I don’t have time’ or see avoidance altogether,” says Senior Vice President Erika Gaudio. “Yet we know patients want to hear from their healthcare professionals whom they trust the most. This program offers an interactive format in which physicians and advanced practice practitioners can role-play and learn from the various case studies in a safe space.”

Clinicians can complete the program in four or more hours. They learn:

Module 1: Covers the typical clinical trajectories and value proposition of hospice
Module 2: Helps identify patients who have a poorer prognosis and assess eligibility
Module 3: Offers approaches to goals-of-care and end-of-life discussions
Module 4: Prepares you to overcome challenges and enhance your communication skills
Module 5: Provides a clinical scenario practice session with interactive role play and feedback from a VITAS preceptor
Module 6 (optional): Offers a live patient encounter with structured feedback from a VITAS preceptor

The program contains five mandatory modules. The sixth module is optional. It consists of a goals-of-care conversation to be completed by the clinician with a patient in the presence of a preceptor who provides real-world feedback and additional resources if needed. An optional seventh module on the topic of cultural competency is expected to launch in 2024.

“Our hope is that providing clinicians foundational knowledge in the context of their current education and experience will help them feel more comfortable to engage in these conversations,” says Dr. Shega.

This article was originally published in August 2022 and updated in April 2024.

Helping Oncologists Treat the Disease While Palliative and Hospice Services Treat the Patient

Tue, 19 Jul 2022 04:00:00 -0400

By Ileana Leyva, MD, Regional Medical Director, VITAS Healthcare

Since the emergence of the hospice programs in 1982, cancer treatment has undergone sweeping changes and advancements, marked by hundreds of new cancer drugs and biologics, genetic technologies, targeted therapies, greater access to clinical trials, and massive investments in cancer treatment centers.

Compared with cancer patients 40 years ago, patients in 2022 are more likely to survive and emerge from treatment cancer free or more likely to function and live at home with cancer for months or years—a trend that presents challenges to hospice services and their focus on end-of-life care.

Today, 67% of cancer patients are survivors living at least 5 years after diagnosis, up from about 50% in the 1970s. (American Cancer Society, 2020)

Still, cancer continues to represent the most common condition for hospice services, and nearly 30 percent of all hospice patients receive care for seven days or fewer, according to the National Hospice and Palliative Care Organization (NHPCO). VITAS Healthcare, the nation’s leading provider of hospice care, feels that seven days is too little, too late, undervaluing the benefits of comfort-focused palliative care and undermining patients’ desires for a dignified, pain-free death when cancer no longer responds as hoped to curative treatment.

Download: Hospice Eligibility Guidelines for Advanced Cancer >

Against this backdrop, VITAS has updated its approach to cancer-specific palliative and hospice care. VITAS continuously provides more services, updating the data we provide to satisfy emerging standards of care for oncology certification and reimbursement. Cancer is the #1 diagnosis for hospice patients (29.6%), ranking third (behind cardiac/circulatory and dementia diagnoses) for Medicare hospice spending. (NHPCO, 2018)

Advanced Stage Cancer: Open the Door for Innovative Hospice Solutions

At VITAS, our cancer-specific solutions include:

A team approach to cancer care, informed by a goals-of-care plan crafted by the patient, family/caregiver, and their VITAS team, which may include a physician, nurse, social worker, hospice aide, chaplain, bereavement specialist, and volunteer
An Oncology Task Force of VITAS physicians and pharmacists who review each cancer referral and make real-time decisions about treatments and medications, based on the patient’s end-of-life goals and expectations
Through utilizing complex modalities to address high-acuity needs, the VITAS team manages aggressive symptoms, including pain, anxiety, dyspnea, nausea/vomiting, poor appetite, constipation, weight loss, fatigue, and more.
A specialized team that oversees individualized plans of care for home visits, goals-of-care conversations, consults, palliative care, and more.
Optional holistic approaches that address symptoms and improve quality of life, including reiki, acupuncture, aromatherapy, pet visits, music therapy, and more

Curative: A Definition Worth Exploring

VITAS is able to continue treatments or interventions that other hospice providers might discontinue.

As a rule, all curative treatments for an advanced disease are halted once a patient is referred to hospice. But with proper documentation and justification, VITAS supports the use of medications and interventions for patients with advanced cancer if doing so:

Provides pain and symptom relief
Improves the quality of life
Prevents adverse side effects or events
Maintains awareness and cognition as death nears

For example, VITAS may continue radiation, chemotherapy, or hormonal therapy for a patient with advanced cancer by leveraging our Oncology Task Force and consulting with one of our medical directors.

Our message to cancer patients: “We can’t cure your disease, but we can address your symptoms based on what’s important to you, your family, and your quality of life.”

A Clearer Path for Cancer Specialists, Too

VITAS delivers a similar message about palliative care to cancer specialists, oncology groups, and hospitals: “While you are treating the cancer, let us address the person and their symptoms.”

And when curative treatments are no longer effective, a VITAS team handles the medical, emotional, and spiritual issues that are prevalent near the end of life. This can include management of symptoms specific to the cancer or its treatment, as well as the psychosocial effects of grief, loss of meaning, income, family role, and more.

The VITAS approach also complements industry changes in oncology certification and reimbursement. The American Society of Clinical Oncology, for example, now requires documentation of palliative care services for certification.

Likewise, other quality-of-care initiatives are tying cancer-related reimbursement to outcome measures that assess such factors as the length of time between a patient’s last chemotherapy dose and death, or the presence of advance directives in the cancer care plan. VITAS can provide both the solutions and metrics that make meeting these higher standards possible.

Hand-in-hand: Oncology Care and Hospice

Too many times, after several weeks on already delayed hospice care, cancer patients will say to me, “I wish I had received these services three months ago, or six months, or nine months ago.”

Cancer treatment, palliative care, and hospice care can and should go hand-in-hand, for the benefit of the patients, their families, and the hospitals and physicians who treat them. VITAS is well positioned as an expert and innovative partner for specialists in their treatment of patients with cancer.

Originally published January 2018 and updated July 2022.

Your Role in Hospice as the Attending Physician

Mon, 13 Jun 2022 04:00:00 -0400

You Are Part of the Care Team

If you refer your patient with advanced illness to VITAS® Healthcare and that patient designates you as their hospice attending physician, you can choose to support their plan of care and bill for the services you provide related to the patient’s terminal prognosis.

As the attending for a VITAS patient, you are an integral member of our interdisciplinary team. You know your patient well, which is why we actively collaborate with you to develop a customized plan of care for them. Throughout your patient’s hospice enrollment period, you can remain involved in direct patient care at the level and frequency you prefer.

The attending can be a doctor of medicine or osteopathy, a nurse practitioner,* or a physician assistant.*

Hospice Helps You and Your Patient

Hospice care with VITAS offers benefits to both you and your patient:

Think of the VITAS interdisciplinary team as an extension of your care in the patient’s preferred care setting. You, your patient, and their caregivers benefit from the support of VITAS, which addresses your patient’s unique physical, spiritual, and psychosocial needs.
Our interdisciplinary teams include a hospice physician, nurse, hospice aide, social worker, and chaplain. Your patient benefits from the comfort, dignity, and personalized care the team brings to the patient’s home.
Our expanded teams ensure patients are receiving the highest level of symptom management and quality of life beyond the hospice benefit requirements, including respiratory therapy, dietary support, PT/OT/speech, music, pet visits, and massage.
VITAS can help inform as well as implement your patient’s plan of care, honoring their care goals, wishes, and values.

The primary goal of hospice and palliative medicine is to manage symptoms and achieve quality of life for patients and families. The research bears this out: Hospice care—more specifically, earlier access to hospice care—is associated with better symptom relief, patient-goal attainment, and quality of care.

Enhancing Quality of Life for Patients, Families, and Caregivers

Recent research conducted by NORC at the University of Chicago (NORC) has revealed a positive correlation between increased hospice utilization within the final six months of life and elevated levels of care satisfaction and quality of life. NORC undertook a thorough examination aimed at appraising the efficacy of hospice care within the Medicare program and its stakeholders, including patients, families, and caregivers. Additional literature supports the NORC study’s findings:

Patients

Patients admitted to hospice within the terminal six-month period reported heightened satisfaction levels, improved pain management, and decreased instances of hospitalization, culminating in diminished physical and emotional distress and an overall improved quality of life.¹

Families

Families of patients receiving hospice care for over 30 days reported the most positive outcomes.^2,4
They noted a heightened probability of patients' end-of-life preferences being honored and rated the quality of end-of-life care as excellent.^2,4
Implementation of home hospice care further mitigated the risk of prolonged grief disorder for families, facilitating tailored pain management interventions and dyspnea support for patients.³

Caregivers

Caregivers reported a decreased incidence of post-traumatic stress disorder (PTSD) associated with home hospice deaths.³

These findings underscore the pivotal role of hospice care in improving the overall well-being of patients, families, and caregivers during the end of life.

Your role as an attending physician, nurse practitioner, or physician assistant allows you to be an integral part of a supportive network, ensuring that your patients receive comprehensive and compassionate care tailored to their unique needs and preferences.

By embracing hospice earlier in the care journey, we not only enhance the quality of life for those facing terminal illness but also bring support to families and caregivers.

Additionally, you can continue to be reimbursed for your patient encounters. The following modifiers are how you bill when you are the hospice attending of record:

Modifier Chart

Modifier	Description
GV	Attending physician not employed or paid under agreement by the patient’s hospice provider; or hospice-employed nurse practitioner acting as attending physician Reported on CMS-1500 by non-hospice attending physician for services provided for treatment or management of conditions related to the patient’s terminal diagnosis Reported on UB-04 hospice claim for physician services performed by a nurse practitioner designated as the attending physician
GW	Service not related to the hospice patient’s terminal condition Reported on CMS-1500 by physician for professional services provided for treatment or management of conditions unrelated to the patient’s terminal diagnosis

Modifier

Description

Attending physician not employed or paid under agreement by the patient’s hospice provider; or hospice-employed nurse practitioner acting as attending physician

Reported on CMS-1500 by non-hospice attending physician for services provided for treatment or management of conditions related to the patient’s terminal diagnosis
Reported on UB-04 hospice claim for physician services performed by a nurse practitioner designated as the attending physician

Service not related to the hospice patient’s terminal condition

Reported on CMS-1500 by physician for professional services provided for treatment or management of conditions unrelated to the patient’s terminal diagnosis

Call 800.93.VITAS to refer today and learn more about the role of an attending physician.

*Nurse practitioners and physician assistants cannot certify or re-certify an individual as terminally ill. Only the medical director/hospice physician is required for recertifications.

**These modifiers are provided for informational purposes only without a guarantee of the correctness or completeness of the material presented. This does not constitute billing advice; healthcare professionals should always consult their own billing or revenue cycle management experts for confirmation of proper billing procedures.

¹Kumar, P., et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432.

²Trella Health (2020). Quantifying Hospice’s End-of-Life Impact. Available at: https://www.trellahealth.com/portfolio_page/ quantifying-hospices-end-of-life-impact/

³Wright, 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.

⁴Kumar, et al. (2017). Family perspectives on hospice care experiences of patients with cancer. Journal of Clinical Oncology, 35(4), 432.

Care Coordination and Hospice: A Cornerstone of Person-Centered Care

Wed, 30 Mar 2022 04:00:00 -0400

We have apps and software to manage it, new models of care and payment to encourage it across all levels of the care continuum, innovative ways to measure its success, and new penalties when providers or organizations fail to deliver it.

Care coordination has been at the foundation of hospice care since it was signed into US law in 1982.

Defining Care Coordination

There are differing opinions of what constitutes care coordination, with a commonly accepted definition being:

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient's care to facilitate the appropriate delivery of healthcare services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care.

In addition to delivering care that is appropriate, coordinated care should also closely align with the care goals and wishes of the individual and his or her family.

Care Transitions Near the End of Life

About a third of Medicare beneficiaries had four or more transitions within their last 6 months of life.¹ For instance, prior to choosing hospice care, patients may transition from an ICU to a skilled nursing facility or spend years going from specialist to specialist, becoming hospitalized for exacerbations only to return to a healthcare plateau and a false sense of functional stability.

Hospice care providers serve as a single entity responsible for ensuring the coordinated care of such patients. This means the hospice care provider is accountable for:

Sharing information with patients’ attending physicians
Keeping patients and families informed
Managing timely transitions between care settings
Providing the right care in the right place at the right time

The Challenges: Transitions and Complexity

All patients are at risk when they transition—between providers or insurance companies, out of the hospital, or onto a new prescription.

Patients with advanced illness are even more vulnerable. Among Medicare patients, approximately 2.3 million seniors are readmitted within 30 days due to complications, at an average cost of $15,500 per patient. (Agency for Healthcare Research and Quality [AHRQ], 2018)

The complexity of these patients’ care can be addressed with enhanced care coordination. They may have multiple chronic or acute health problems. They may see multiple health care professionals in multiple locations and associated with several health systems. They may be unable to organize their own care, from keeping appointments to buying and taking prescribed medications. They may also face social challenges, from isolation to financial hardship.

These patients’ attending physicians once primarily coordinated their care, but with more complications comes an increasing need for a care team that proactively coordinates care on a patient-by-patient basis.

This is where the hospice care model’s interdisciplinary team steps in to coordinate support based on the patient’s individualized plan of care. As patients move from conventional to supportive care—often from ineffective, overly intensive, and costly care to patient goal focused comfort care; from disease-focused care to person-centered care—hospice addresses their specific needs while preventing unnecessary, burdensome hospital visits and admissions.

Benefits to Care Coordination within Hospice

There is a great value in physicians and hospice care providers coming together to create a connected care community.

In addition to improving quality of care, this association promotes:

Timely Referral
- Referring hospice patients sooner frees up treatment time for new patients
- Patients receive the benefits of hospice care sooner, improving their quality of life during their remaining time
Shared Decision-Making
- When a team of clinicians take part in the transition decision, patients are reassured that they are making the right decision in turning to hospice care
Easy Access to Shared Data
- Via technology, physicians can review patient data and gain a more holistic view of the patient’s health trajectory, treatments, and behaviors

The Key is Interoperability

The fragmentation of post-acute care in earlier years has led to a need for care coordination between hospice care providers and physicians. To address this fragmentation, VITAS has adopted technology to facilitate enhanced coordination between hospice care teams and attending physicians.

Specifically, VITAS’ fully mobilized nursing units, supported by IT experts, use leading-edge technology to work in conjunction with attending physicians to provide person-centered care on-the-go. These easy-access, anywhere and anytime tools make it easier to coordinate care between care settings and medical experts.

They also allow the patient’s full team of experts, including nurses, social workers, and other specialists, to view the patient’s care plan and order home medical equipment and prescribed medications as needed.

Bridging the Gap Between Hospice and Attending Physicians

VITAS administers person-centered care by working alongside attending physicians on a patient-by-patient basis.

The increased complications experienced by patients with advanced illness result in an increased need for a care team that proactively coordinates care on a patient-by-patient basis. Hospice should be a top-of-mind recommendation for eligible patients because it provides an interdisciplinary team approach in their preferred setting, incorporating these care approaches:

Holistic
Psychosocial
Educational

Our specialized experts rely on communication, documentation, and devices that allow real-time information sharing, while maintaining respect for one another’s professional expertise to ensure the effective delivery of collaborative healthcare services.

Our goal is to lead safe, effective, comprehensive care and prevent unnecessary, burdensome hospital visits and admissions.

¹Wang, S. Y., Aldridge, M. D., Gross, C. P., Canavan, M., Cherlin, E., & Bradley, E. (2017). End‐of‐Life care transition patterns of Medicare beneficiaries. Journal of the American Geriatrics Society, 65(7), 1406–1413. https://doi.org/10.1111/jgs.14891

Strategies for Advocating and Delivering End-of-Life Care in Diverse Communities

Tue, 08 Feb 2022 05:00:00 -0500

During a recent interview, three executives from the VITAS Healthcare hospice team in Atlanta, Georgia, discussed the unique challenges and opportunities involved in providing hospice care and recruiting healthcare workers in large, diverse communities.

Atlanta is one of the largest, most diverse metropolitan areas in the US. Metro Atlanta Chamber 2020 statistics show the racial breakdown of its 6+ million residents as 46% White, 33% Black or African, 12% Hispanic, 7.7% two or more races, and 6% Asian.

The biggest challenges to providing hospice care, they agree, are overcoming common misconceptions about what it is: a medical specialty that patients actively choose in order to focus on comfort and quality of life near the end of life in the setting they prefer to be.

Successful Outreach to Communities of Colors

Robert Perez: The best way to reach large, diverse groups of people is to engage with the trusted healthcare professionals within their communities—to talk to their doctors. That way, patients and residents are hearing about hospice care from someone they trust.

Black and Hispanic nurses also play very important roles in ensuring that members of their families, communities, and faith groups can utilize the Medicare hospice benefit, which pays for up to 100% of care.

Many people pass away without the benefit that they have worked for their entire life and deserve to have at the end of life. Increasing awareness of the hospice benefit is a unique, meaningful way for nurses to serve.

Overcoming Language Barriers

Robert Perez: Be aware of language barriers that can lead patients to feel misled or inadequately treated. In Spanish, for example, the words "hospicio” and “hospital” sound almost exactly the same. Patients might choose hospice care assuming that everything will be done to treat their illness, as would happen in a hospital.

Acknowledge language barriers and be sure to work through them for clarity.

The ‘Human’ Approach to Hospice Conversations

Kevin Goodlow: People need to see us outside of our roles as physicians and practitioners. I find it very fruitful to share my own personal experiences with hospice care.

When my mom was on hospice care, I wasn't Dr. Goodlow. I was Kevin, my mother’s son, and I was often full of emotion—and that was OK. When I can share that experience with my patients and families, they’re more likely to see me more as a person, and not the guy in the white coat with a perfect life and no real problems. It helps them understand that we’re all human beings with families, all living and dealing with similar issues.

The more they trust you, the easier it is to connect with them one-on-one. And when you connect, you’re more likely to move them toward hospice as a care option.

Where to Start? Get our Guide to Having the Conversation >

A Role for Nurses in Advocating for End-of-Life Care

David Blake: I always remind nurses in Atlanta and at National Black Nurses Association (NBNA) end-of-life educational trainings, that many of them have undergone more training in end-of-life care than some physicians and specialists. Because of their training, they can "gently suggest" to physicians that hospice might be an option to consider when discussing a patient’s care.

Many physicians, in fact, are attentive to an educated suggestion from a nurse: “Hey, doctor, how about we consider hospice?”

On Becoming a Hospice Nurse

Robert Perez: Hospice nursing is one of the few places in healthcare where the RN has a tremendous amount of autonomy. They’re still under the supervision of a physician, but it’s the nurse who is out in the field and at the bedside day in and day out with patients and their families. Physicians rely on the nurse to be the eyes and ears of the patient to decide the plan of care. Within their scope, hospice nurses practice a much higher level of care than you typically see in other settings. There’s a lot of flexibility in the care they provide and how they plan their day. They might spend a few weeks, months, even a year with a patient, and they’re able to truly bond with the family. It’s a unique, special relationship with a lot of autonomy.

David Blake: Not every nurse can make a great hospice nurse. Spending that amount of time with a family can be very draining, and we know how the story is going to end. We’re basically helping patients and families transition to the end of life. For nurses who want to develop relationships with families and exercise a higher level of independence on a team with a high degree of autonomy, hospice nursing is a unique career path: a path we know some NBNA members have embarked on and we hope more members will consider.

Robert Perez is general manager for VITAS Healthcare in Atlanta, Georgia; Dr. Kevin Goodlow is medical director, and Dr. David Blake is associate medical director.

Heart Failure Mortality High and Prognosis Poor, Regardless of EF Classification

Thu, 27 Jan 2022 05:00:00 -0500

By Heather Veeder, MD, Regional Medical Director, VITAS Healthcare

This article was published in January 2022 and updated in April 2024.

Heart failure (HF), which affects over 37 million people worldwide, is a major cause of morbidity and mortality, especially among older adults.

HF is classified by left ventricular ejection fraction (EF); the American College of Cardiology and American Heart Association categorizes HF as such:

Heart failure with reduced ejection fraction (HFrEF) - EF ≤40%
Heart failure with borderline ejection fraction (HFbEF) - EF 41%-49%
Heart failure with preserved ejection fraction (HFpEF) - EF ≥50%

These different subcategories of HF have different clinical characteristics, and while EF is a major differentiator when guiding management and treatment of HF, there does not appear to be major differences in mortality and prognosis between EF subgroups, as shown in a study by Shah, et al. published in the Journal of the American College of Cardiology.

According to the study, heart failure is associated with markedly lower median survival, poor long-term prognosis, and increased risk of cardiovascular and heart failure admission, regardless of ejection fraction classification.

Median Survival of Patients Hospitalized with HF

The study analyzed data from the GWTG-HF (Get With The Guidelines–HF) registry and claims data from the US Centers for Medicare and Medicaid Services (CMS), and thus examined data from 39,982 patients from 254 hospitals admitted for HF between 2005 and 2009.

These patients, who were all fee-for-service Medicare beneficiaries age ≥65 years hospitalized with a diagnosis of HF, were divided by HF subgroup:

18,299 (45.8%) had HFpEF
3,285 (8.2%) had HFbEF
18,398 (46.0%) had HFrEF

The study examined the median survival of patients hospitalized with HF compared to the general population. It also examined 5-year outcomes between different EF groups, including mortality, all-cause readmission, cardiovascular readmission, heart failure readmission, and the composite mortality/readmission rate.

Regardless of EF, median survival for patients with HF was similar and declined with advancing age. Within each age group, median survival for patients with HF was significantly lower the general US population, as seen in the figure below:

For example, among patients 65 to 69 years of age, median survival was ≤4.0 years. In contrast, according to the National Vital Statistics Report for the general US population, the median survival of individuals 65 to 69 years of age is 18.7 years. In this age group, patients with HF lost up to 15 years of life.

Examination of mortality data across all age groups shows similarly markedly lower median survival rates among patients with HF compared to that of the general individual life expectancy in the United States, with median survival for patients with HF roughly 5 times shorter than the general population.

Mortality, Readmission Rates Were Similar in All Groups

The findings in this study show that in this very large national registry-based HF patient cohort, mortality and readmission rates were similar in all groups irrespective of EF classification with and without risk adjustment. The figure below compares five-year outcomes:

There was no significant interaction between time and EF groups for any of these outcomes. These similarities across EF groups held true even when adjusting for patient demographics, medical history, examination findings, laboratory findings, and medications, as well as when looking at event-free patients who survived the first 6 months or 1 year post-admission.

The authors of this study conclude that "in patients age ≥65 years hospitalized with HF, 5-year risk of all-cause mortality is high regardless of EF, and the median survival is substantially lower than the general population of similar age."

Hospice Addresses Heart Failure's Complex Challenges

Heart failure is a clinical syndrome with significant morbidity and mortality. It places a substantial burden on both patients and health care systems. Patients with HF bear a heavy disease burden, making them prime candidates for hospice.

As the study by Shah, et al. shows, mortality is high and prognosis is poor in HF patients regardless of EF subgroup classification. Rehospitalization rates for all-cause, cardiovascular, and HF readmission are also high between EF subgroups.

While clinicians use EF classification to make decisions regarding management and treatment of HF, EF categorization is not a requirement for hospice admission; a diagnosis of HF is sufficient.

Hospice is uniquely equipped to address the complex challenges that advanced HF presents. There is ample opportunity in the population of hospice-eligible patients with HF, regardless of their EF classification, for hospice to potentially provide reduction in morbidity and disease burden, reduction in hospitalization and readmission rates, and increase in patient and family satisfaction.

Shah, et al. Heart failure with preserved, borderline, and reduced ejection fraction: 5-year outcomes. Journal of the American College of Cardiology. 70.20: 2476-2486.

COVID-19 and Multimorbidity: Exploring the Hospice Option for Care

Tue, 11 Oct 2022 04:00:00 -0400

COVID-19 has transitioned from a life-defining illness to one that exacerbates underlying medical conditions.

According to a study published by the National Center for Biotechnology Information in December 2021, hypertension, cardiovascular disease, and diabetes were among the most common comorbidities in patients who died from COVID-19. More than half of the patients had two or more comorbidities at their time of death.

Though Omicron and other new variants are not as severe, hundreds of people die each day from COVID. -VITAS Chief Medical Officer Joseph Shega, MD

Specific advanced conditions, when combined with COVID-19, are more likely to cause clinical trajectories that trigger the need for end-of-life care. These include advanced heart failure, advanced lung disease, dementia, and cancer.

“With multimorbidity, patients may transition from serious illness to advanced illness,” explains Dr. Joseph Shega, chief medical officer for VITAS Healthcare. “Some of these patients who get COVID-19 will recover to a new lower baseline but still not be hospice-eligible. Others will present exacerbations of underlying disease, with COVID driving further decline. They now become hospice-eligible.”

To provide compassionate care for patients with these trajectories, an interdisciplinary team of hospice clinicians, case managers, social workers, and other care professionals may be the best option.

When Patients Become Hospice-Eligible

The severity of the underlying disease, multimorbidity, and COVID-19 symptoms will together indicate the next stage of medical care. Patients are eligible for hospice care when a physician makes a clinical determination that life expectancy is 6 months or less if the disease runs its expected course.

Some patients who get COVID may recover to a lower baseline but not be hospice eligible; others may present exacerbations of underlying disease and become hospice-eligible.

Common Hospice-Eligible Conditions

When these disease states have advanced to the level described below, it may be time to explore hospice care. Only a physician can determine hospice eligibility for a patient.

“Hospitals may see patients who were hospice-eligible before getting COVID, yet not identified as such,” says Dr. Shega. “Once the patients arrive at the hospital with COVID, their condition becomes more apparent. Their physician begins considering a referral to hospice so they can receive the support services they need.”

Advanced Heart Failure

NHYA class III or IV
ED visits, hospitalizations within the last 6 months

Advanced Lung Disease

SOB at rest/minimal exertion on oxygen
ED visits, hospitalizations within the last 6 months

Dementia

3/6 ADL dependency
Clinical complication in the last 6 months: aspiration pneumonia. UTI, sepsis, multiple pressure ulcers, weight loss

Cancer

Metastasis
ECOG 2/3

Case Study: High-Acuity Patient Tests Positive for COVID-19

An 82-year-old is admitted to the hospital for 5 days. The patient was at home and experienced worsening normal ejection fraction (EF) heart failure (HF).

In addition, the patient had a medical history including baseline NYHA Class II-III, long-standing hypertension, diabetes, stroke, and arthritis.

With symptoms including fatigue and a positive COVID-19 test, which was thought to exacerbate heart failure, the patient sought treatment. Despite optimized medical management, the patient’s new baseline moved to NYHA Class III-IV HF.

The patient’s primary care physician referred the patient to VITAS after a post-hospital discharge and a goals-of-care conversation. The patient was admitted to hospice care at home. The VITAS registered nurse on the hospice team ordered oxygen, home medical equipment, and medications.

Weekly visits from a nurse, aide, social worker, and chaplain began, along with physical therapy. The team provided higher levels of care and complex modalities. They also adjusted the patient's medications and treatments for comfort.

Through early referral to hospice, the patient received 112 days of care. In total, the hospice team members made 84 visits, managed 8 medications, and provided 5 types of home medical equipment. This high-acuity patient had 10 after-hour visits and Telecare calls. The patient’s level of care changed twice, with 5 days spent in Intensive Comfort Care^®.

Why Consider Hospice

Studies indicate that increases in COVID positivity rates are related to a drop in temperature throughout the winter months.¹ During this colder season, patients with multimorbidities should remain aware of all of their care options, especially those facing advanced illness.

Nearly 70% of Americans indicate they would prefer to die at home, if given a choice.² Hospice care can help patients achieve that goal at end of life.

“Though Omicron and other new variants are not as severe, hundreds of people die each day from COVID. The onset of COVID greatly intensifies a patient’s risk. Those with serious illnesses may decline,” says Dr. Shega. “Once deemed hospice-eligible, they can receive the quality of life care they desire from a hospice team.”

Patients' families share a favorable view of hospice care:

More than 70% of families rate the care as "excellent" when patients received hospice care.³
Less than 50% of families rate the care as "excellent" when patients died in an institutional setting or with home health services.³

Timely hospice referral ensures patients can receive more care with the VITAS model, ensuring we coordinate with your practice and keep the symptoms of their disease managed.

¹Liu, X., Huang, J., Li, C., Zhao, Y., Wang, D., Huang, Z., & Yang, K. (2021). The role of seasonality in the spread of COVID-19 pandemic. Environmental Research, 195, 110874. https://doi.org/10.1016/j.envres.2021.110874

²Kaiser Family Foundation/The Economist Four-Country Survey of Aging and End-of-Life Medical Care (2017). Conducted March 30–May 29, 2016.

³Teno J.M., Clarridge B.R., et al. (2004). Family perspectives on end-of-life care at the last place of care. JAMA, 291(1):88–93

Finding Common Ground During Goals-of-Care Conversations

Wed, 15 Dec 2021 05:00:00 -0500

Matters of health are always central in goals-of-care conversations. But how might your patient’s religious beliefs affect their wishes for treatment?

I try to connect families with imams or chaplains to explain that palliative and hospice care do not infringe on their beliefs.-Munima Shaikh, MD, VITAS palliative care physician

The hospice discipline and care model acknowledge the significance of spirituality at the end of life: Every hospice care team features a chaplain and bereavement specialist to support patients and families through the complex questions, fears, and trials of faith that mark the journey toward death.

Still, patients may have misconceptions or concerns about hospice, perceptions that are rooted in their spiritual ideals.

Healthcare professionals helping patients to prepare for a transition from curative to comfort-focused care can reduce hospice hesitancy—and ensure patients’ end-of-life spiritual needs are known and met—by asking about religious beliefs, concerns, and preferences as part of a routine goals-of-care conversation.

Challenging Misunderstandings

Among both religious and secular hospice-eligible patients, lack of understanding about hospice services presents an obstacle to accepting care. A 2018 study found that 37% of polled respondents had misperceptions about hospice care and 53% had misperceptions about palliative care.

Common misunderstandings include the idea that hospice speeds up death, or that it aims to sedate patients to the point of unconsciousness.

In fact, research suggests that hospice can actually help dying patients live longer, more comfortable lives, with more opportunities to share meaningful experiences with loved ones. Hospice teams also embrace non-drug modalities for pain relief and comfort, including gentle massage, meditation, prayer, and virtual reality therapy.

To clear up this confusion, clinicians should ask patients questions about the source of their concerns. Once a mutual understanding is established, clinicians can educate in terms that everyone can grasp.

Embracing Education

“Most patients’ family members are receptive to education. If you sit down and talk about why you use pain medication [for instance], most people are receptive,” says Munima Shaikh, MD, a palliative care physician for VITAS in Orlando, Florida.

As a Muslim, she’s proud to help other followers of Islam understand how hospice fits into the teachings of their religion—some interpretations of which suggest that pain near death serves to purify the soul before it reaches the afterlife.

For more complex spiritual questions, Dr. Shaikh gladly reaches out to specialists on her team and members of the community.

“I try to connect families with imams or chaplains to explain that palliative and hospice care do not infringe on their beliefs,” she says.

‘He Was Trying, and That Matters’

Sometimes, religious patients’ concerns about hospice stem from uncertainty about a provider’s ability to meet their specific spiritual needs, says Sunil Pandya, MD, associate medical director in Collier County, Florida.

“It’s not that Muslims, or in my case Hindus, believe that dying with dignity is bad. It’s that we don’t know if hospice knows what we want,” he says. “Do they know about my father’s vegetarian diet? About facing a Muslim’s bed the right way? Do they know the right prayers to say and when to say them?”

Dr. Pandya says that in these cases, a little compassion and effort can go a long way toward helping a patient and family feel more accepted by their care team, and more satisfied with the care they receive.

For him, this concept is personal: his father was a VITAS patient.

“My friend Tom was a chaplain at VITAS,” Dr. Pandya explains. “Although Tom was a Christian, he came into my dad’s room and read Vedic Hindu prayers in English to my dad, and that really meant a lot. He was trying, and that matters.”

Healthcare professionals whose patients follow an unfamiliar religion may naturally fear saying or doing the wrong thing at the wrong time. Most clinicians want to go above and beyond to support their patients—but without crossing unspoken boundaries.

As Dr. Pandya points out, trying your best to meet a patient’s spiritual needs demonstrates a level of commitment and compassion that both the patient and their family are likely to notice and appreciate.

Treating Patients as Individuals

Many cultural notions about death and dying are rooted in religion. Even nonreligious patients and families may hold some spiritual ideas about dying, death, or the rituals that follow it.

Prior to a goals-of-care discussion, clinicians can prepare for common questions and concerns by studying popular ideas about death from religious and secular thinkers.

Of course, every patient and family—no matter how religious or what tradition they follow—will have their own unique take on religious ideas.

In Buddhism and Hinduism, for example, suffering is considered an accepted part of life, and believers may expect to be stoic when facing its challenges, including illness and death. People from parts of the world where these traditions are common may share that view of suffering, even if they are not believers themselves.

Clinicians should be adaptable and accountable: Ask directly about a patient’s approach to religion to avoid awkwardness or miscommunication, and if you make a mistake, simply apologize, and commit to doing better.

Take the time to ask yourself: Do you really engage with the patients and families, or do you just make assumptions?

Healthcare professionals often think that they just need to bring in someone that speaks the patient’s language—but do you really know what they need or want on a personal level?

Having the Conversation

Advance care planning/goals-of-care discussions are ideal opportunities to build trust, overcome concerns, and develop a roadmap for a patient’s care that satisfies their unique needs and preferences.

Make your next conversation count with guidance from VITAS, the nation’s leading provider of end-of-life care. Download our Guide to Goals-of-Care Discussions today >

Talking About EOL Wishes, Values Is Just As Critical as Providing EOL Care

Wed, 17 Nov 2021 05:00:00 -0500

By Henri Nammour, MD, Regional Medical Director, VITAS Healthcare

Two findings caught my eye in the Lee, et al., study of POLST documents and ICU admissions:

The first involves data: 38% of patients received unwanted, goal-discordant intensive/interventional care near the end of life.
The second is the researchers’ quoted observation: “The experiences of ICU patients and survivors suggest that patients receiving aggressive, life-sustaining treatment experience a high burden of unrelieved physical symptoms and emotional distress.”

For patients who do not want aggressive treatments as they’re dying, unwanted intensive care also incurs “physical, emotional, and financial costs while providing little value,” the researchers point out. Clinicians understand that care provided near the end of life represents a disproportionate amount of health care expenditures.

In essence, nearly 40% of patients—even if they have clearly documented their wishes for end-of-life care with limited intervention or comfort measures only— are still not able to die the way they prefer to die: without pain or intrusive care, in the place they call home, surrounded by loved ones and family.

Quick Facts: 7 Things to Know About Advance Directives for Your Patients >

With an eye on comfort and compassion, physicians and clinicians must be more aggressive in their discussions with patients about their goals, preferences, and values as they approach the end of life.

It is critically important to talk honestly and openly with patients about the care they want as they are dying. And, among patients who receive care not consistent with POLST, we must continue to engage in goals-of-care conversations to ensure wishes and values are met.

Dr. Illeana Leyva and Dr. Eric Shaban, VITAS regional medical directors, give a step-by-step demonstration of how to approach a goals-of-care conversation.

VITAS Maintains, Deepens Its Reputation as an LGBTQ-Friendly Hospice Provider

Thu, 14 Oct 2021 04:00:00 -0400

For LGBTQ+ patients, their partners, and their families, seeking traditional healthcare is often fraught with concerns about discrimination from physicians and other healthcare professionals, as well as issues of respect, trust, and the fear of divulging very personal and often sensitive information.

When members of the LGBTQ+ community are referred to hospice care, those concerns and worries can intensify as they confront:

the end of their lives
the end of loving relationships
remnants of fractured family relationships
numerous psychosocial and spiritual issues associated with death and dying

Those very challenges underscore VITAS’ ongoing commitment to provide compassionate, sensitive, nonjudgmental hospice care to patients who identify as LGBTQ+: lesbian, gay, bisexual, transgender, queer, gender non-conforming, or other.

Research Finds Need for Respectful LGBTQ+ Hospice Care

The VITAS commitment to the LGBTQ+ community addresses a need identified by population research.

Members of the VITAS team, like Jaime Collazo, take time to educate the LGBTQ+ community about hospice care so they are empowered to make the best choices for themselves and their families.

A 2018 AARP survey of older (ages 45+) LGBT participants found that while 84% reported honest and open relationships with their healthcare providers:

52% expressed concerns about discrimination or prejudices that could affect the quality of healthcare they receive
57% were concerned about healthcare providers not being sensitive to the needs of LGBT patients

A 2020 Kaiser Family Foundation survey found 36% of LGBTQ+ patients (vs. 22% non-LGBTQ+) reported at least one negative experience with a healthcare provider: being blamed for their health problems, having their concerns dismissed, not being believed, or being subjected to uninformed assumptions.

According to a 2020 study (Stein, G., et. al) of 865 hospice and palliative care physicians, social workers, nurses, and chaplains, published in the Journal of Palliative Medicine:

53.6% of providers said LGBTQ+ patients were more likely than non-LGBTQ+ patients to experience discrimination at their institutions; 27.3% observed such discrimination
64.3% said transgender patients were more likely than cisgender patients to experience discrimination; 21.3% observed such discrimination
- Examples included disregard or minimization of LGBTQ+ patients’ spouses/partners treatment decisions (15%), and disrespectful treatment of a patient’s spouse/partner or surrogate (14.3%)

“Disrespectful care can negatively impact the trust patients have in providers and institutions, and lead to delaying or avoiding care, or not disclosing relevant information,” wrote the researchers, who suggested LGBTQ+ advocacy and training for hospice and palliative care providers.

Authenticity and Support for LGBTQ+ Communities

Diane Rapaport, MD, a home care physician for VITAS in Chicago, feels that LGBTQ+ patients and their partners and families benefit uniquely from the support of the seven-member interdisciplinary hospice team that’s required by the Medicare hospice benefit.

I will put my money in the bank that no other hospice provider has done what we have done.-Nancy Auster, VITAS admission RN

“Our specific contribution as hospice professionals is having a whole team that can be there for intervention and care,” Dr. Rapaport says. “The medical-psychosocial interdisciplinary team is often the key that’s necessary to help resolve estranged relationships, which are particularly common in the LGBTQ+ community. These patients are more likely than others to have estranged relationships with family members, and more specifically, they are more likely to have been abandoned by, judged, or denied access to their own religion.”

The hospice team’s chaplains, social workers, music therapists, and other specialists can intervene to “help them find peace through spiritual connectedness and by not abandoning them,” she says.

Nancy Auster, an admission RN, joined VITAS in 1991 on a dedicated team that cared for HIV/AIDS patients in South Florida. Her early involvement in outreach to hospice patients with AIDS inspired her to continue to advocate for the LGBTQ+ community “because I was so inspired by this population that was underserved and misunderstood. I still feel very connected as an ally,” she says in her third decade at VITAS.

“If I encounter any patients in the LGBTQ+ community who need or want to hear about hospice care, I want to be the one to escort them into our services with the utmost dignity and respect they deserve, and make sure they get the special care and attention they need,” says Auster.

‘A Policy of Inclusiveness’

VITAS has had an active, visible presence at LGBTQ+ events for more than three decades.

VITAS provides education, resources, training, and grief support groups for the LGBTQ+ population. At LGBTQ+ healthcare events, VITAS has sponsorship tables with banners featuring the Pride flag and VITAS logo.

“We hand out fans and brochures with LGBTQ branding and information,” Auster says. “I will put my money in the bank that no other hospice provider has done what we have done.”

“In most of our markets, we’re one of the only hospice providers that reaches out to the gay community, and if we’re not the only one, we’re one of only a few,” says Jaime Collazo, director of market development in Broward County, Florida.

Broward is home to Wilton Manors, a city featuring one of the largest LGBTQ+ populations in the US per capita, a particularly high proportion of whom are gay seniors.

For healthcare professionals, a free VITAS continuing education course addresses best practices when caring for patients from the LGBTQ+ community and ways to overcome their unique concerns about medical care.

Professional, Purposeful End-of-Care

“One of our core corporate values is ‘we take care of each other,’” says Diane Psaras, chief human resources officer at VITAS. “When we treat our associates with the professionalism and respect they deserve, we are setting an example for the kind of purpose-driven care and committed professionalism we expect of them in their interactions with our patients, families, healthcare partners, and communities.”

During the VITAS 40th anniversary in 2018, we documented our early and unique-to-the-industry efforts to care for patients affected by the HIV/AIDS crisis of the 1980s-90s.

Our dedicated outreach and commitment to provide compassionate hospice care to AIDS patients—the majority of whom identified as gay—continues with purpose today for LGBTQ+ patients, regardless of their sexual orientation, gender identity, or diagnosis.

Rabbi Jane Rachel Litman, a VITAS chaplain in San Francisco, California, points out that even in the Bay Area, VITAS stands out as a hospice provider that conscientiously sponsors and provides targeted LGBTQ+ services. That includes sponsorship of an LGBTQ+ grief bereavement group that she facilitates at an LGBTQ+ community senior center.

“It’s important for us as healthcare workers to affirm LGBTQ+ people, acknowledge their right to healthcare and hospice access, and treat them with human respect and dignity,” she says. “Our visibility in this community is one of the many reasons I’m proud and happy to work for VITAS.”

Validating LGBTQ+ Hospice Patients

Mon, 27 Sep 2021 04:00:00 -0400

To create truly individualized hospice care plans, compassionate healthcare providers and care teams must understand and respect their patients’ different cultures, religions, traditions, languages, and sexual identities without judgment or discrimination.

VITAS leads the way in inclusive care for LGBTQ+ hospice patients, a longstanding commitment that makes a real difference in providing patient-centered end-of-life care for them and for their partners and families.

“LGBTQ+ people continue to experience discomfort when accessing healthcare, and that is heightened when one becomes more vulnerable, such as at the end of life and in hospice,” says Joseph Shega, MD, VITAS chief medical officer. “We need to be aware of that, address it in a thoughtful, compassionate, and caring way, and respect whatever they decide.”

In recognition of LGBT History Month in October, VITAS experts endorse these best practices that support respectful, dignified, and informed care for patients who identify as LGBTQ+, and for their partners and families.

Tips for LGBTQ+ Healthcare:

Make no assumptions about a person’s sexual identity. The landscape of sexual identity, gender, and sexual orientation is broad and evolving, so be careful not to mis-gender or mis-identify patients.
If you’re unsure of a patient’s sexual identity, ask simple questions: How do they wish to be identified? What are their pronouns? What words should you use and not use? How should you refer to their partner? Common pronouns are she/her, he/him, they/them, zie (pronounced “zee” and replaces she/he/they) or hir (pronounced “here” and replaces her/hers/him/his/they/theirs); or ask patients directly if there are others they use.
Similarly, make no assumptions about whether a person has divulged their sexual identity to everyone who visits, including family and friends. Give each patient space to explain their disclosure, defer to their decisions about who knows what, and respect their privacy during each visit/encounter, especially when others are in the room/vicinity.
When involving family members, ask direct questions about whether family members are a patient’s birth/related family or the friends/partners they have chosen as their family members, usually because of rejection by their biological family. Based on their responses, involve them accordingly. Know who is the legally designated representative for a patient’s healthcare decisions.
Be aware of generational differences in LGBTQ+ language. Example: Some younger couples might call themselves “husbands” or “wives,” while some older couples might prefer the term “partners.”
Let the patient and partner/family set the stage for the care they prefer. Listen with an open mind and take cues from them about how much information they are willing to provide and when they feel comfortable divulging it.

Psychosocial Care Guidelines for LGBTQ+ Patients

Identify current sources of stress for each patient (e.g., family conflicts, lack of/partial/full disclosure, isolation, estrangement, rejection, alienation, loss, depression, anxiety, etc.).
Encourage involvement in activities that build resilience and help patients cope (e.g., support groups, meditation, community involvement, journaling, volunteering, the arts, etc.).
Be willing to let your patient educate you about their emotional or psychological issues. Ask for clarification if you don’t understand.
Understand that interacting with LGBTQ+ patients’ biological families can be challenging, especially if they are dealing with the patient’s illness and issues of the patient’s sexual identity, disclosure, or lifestyle. When possible, connect families/friends with supportive community resources, such as PFLAG (Parents and Friends of Lesbians and Gays) or GLAAD (Gay & Lesbian Alliance Against Defamation).
Remind patients to update and sign all legal documents about their care so that their wishes are honored.'
Avoid judgment when caring for patients who are HIV-positive; treat them with the same level of compassion as you treat other patients with life-limiting illnesses.

Spiritual Care Guidelines for LGBTQ+ Patients

Be aware that some patients may have had negative experiences with formal religion or religious leaders, especially denominations that condemn LGBTQ+ identities. Provide a welcoming space for exploring their feelings and past experiences, and take direction from them about how to proceed.
Discuss healthy spirituality and connect patients/partners with compassionate chaplains and churches, synagogues, and other faith communities that openly accept LGBTQ+ people.
Be prepared for feelings of guilt, shame, anger, and rejection (“Why doesn’t God love me?” “Why do some people feel I’m a sinner?” “How can the way I’ve been rejected be God’s will?”). Help them explore which feelings should be challenged and overcome.
Discuss with patients how they want their memorial service to be conducted, and what information they want included/excluded from their memorial service and obituary.

Guidelines for Care of Transgender Patients

As they’re examining or caring for transgender patients, hospice nurses and aides are more likely than other members of the interdisciplinary team to encounter human bodies that have undergone or are undergoing a hormonal and/or surgical transition from male to female or from female to male.

Keep thoughts to yourself and silent during physical examinations when you encounter scars, tattoos, or other anatomical markers that indicate completed or ongoing transition (e.g., breast reconstruction/mastectomy, genital surgery, etc.). Instead, take cues from your patient and assess their comfort level with divulging information or answering questions. Ask simple questions to gather the relevant information you need for each patient’s hospice care.
Pay attention to patients’ reactions during physical examinations, keeping in mind that some—especially women—have been victims of sexual violence. Simple acts of care, including a touch, giving a bath, or conducting a physical exam, can trigger traumatic emotions and experiences. Give patients the space, privacy, and supportive resources they need if these kinds of reactions or emotions arise.
Remember: the degree and manner of an individual’s transition is a personal choice. Many transgender people elect not to pursue gender-affirming surgeries or hormonal treatments. Others are barred from these measures by circumstance. Affirm your patient’s gender identity by using pronouns based on their usage rather than your perception/assumption.

New Tool for Clinicians: Opioid Converter for Patients with Advanced Illness

Tue, 09 Nov 2021 05:00:00 -0500

The VITAS mobile app for clinicians now includes an opioid conversion tool that helps healthcare clinicians treating patients with advanced illness. The opioid conversion tool is meant to help clinicians make more relevant decisions about the goal-focused, pain-relieving medications they prescribe to patients with advanced illness and hospice patients.

This tool is tailored for clinicians caring for patients who:

face the symptoms associated with advanced illness and
have chosen to receive or are eligible for palliative care or hospice services, with a focus on comfort and quality of life near the end of life.

The VITAS tool differs from other opioid converters by including key clinical factors that inform and guide conversions specifically for patients with advanced illness. The VITAS tool is calibrated to their unique needs and functional status, and it is supported by decades of experience providing care that meets patients’ goals and preferences for care near the end of life.

A Clinically Driven, Patient-Centered Approach to Pain Management

Pain becomes more commonplace as patients near the end of life, which has led to the use of opioids as a standard treatment. With the wider availability and use of opioids among the general population over the past decades, some patients who come to VITAS for hospice care are already on a variety of medications and opioid therapies.

This tool standardizes our approach to opioid use as patients near the end of life, and it helps mitigate opioid overuse by embracing a clinically driven, patient-centered approach to pain management. The converter is also built on data-driven, real-world evidence to ensure opioids are used consistently and as safely as possible in a patient’s final months, weeks, and days. The converter’s utility mitigates the risks of varied practices and inconsistent protocols among healthcare professionals who might not be familiar with the unique needs of patients who are dying.

A Standardized, Hospice-Specific Approach to Opioid Prescribing

To date, most calculators have been designed for patients who are prescribed opioids for conditions or diagnoses for which they are still receiving curative treatment.

VITAS medical directors, physicians, clinicians, executives, nurses, and our in-house pharmacy operations staff saw the need for an opioid conversion tool tailored specifically to the symptoms and conditions experienced by patients who have advanced disease or who are actively dying.

VITAS is and always has been committed to the responsible use of opioids, supported by individualized care plans for each hospice patient.

Not only is the VITAS converter part of our mobile app for 24/7 availability and ease of use at a clinician’s fingertips; it also incorporates functionality for the hospice specialty:

Clinicians who use the app can view a patient’s current opioid usage and assess a new drug titration, based on disease, symptoms, and factors that are unique to each patient.
Physicians and clinicians can incorporate clinical judgment and additional information into their prescribing decisions, such as a hospice patient’s underlying disease(s), comorbid conditions, functional decline, frequency of dosing, and factors as critical as a patient’s physical ability/inability to swallow or inhale certain medications.
Aided by this additional information, prescribing clinicians can identify the right medication, delivery method, dose, and dosage schedule so that hospice patients receive care that eases their pain/symptoms and allows them to embrace quality of life near the end of life.

Consider these examples of opioid-prescribing decisions that are unique to hospice patients:

A patient who is dying from chronic obstructive pulmonary disease and has underlying kidney disease can be prescribed a long-acting opioid that is titrated to underlying symptoms, including breathlessness and pain.
A patient who is prescribed several short-acting opioids for intense, unrelenting pain from breast cancer that has metastasized to the bone can be switched to a longer-acting opioid to ensure consistent drug delivery, ongoing pain relief, and an improved quality of life.

In-House and Referral-Partner Utility

At VITAS specifically, the conversion tool helps standardize prescribing practices throughout all our teams while honoring patients’ wishes and clinicians’ clinical judgments and decisions. Patients also can be supported by hospice’s non-pharmacological modalities to address pain, including acupuncture, music therapy, gentle massage, pet visits, virtual reality therapy, and more.

For referral partners who rely on our app, the converter provides readily available information and guidance on a topic that is not frequently covered in depth during medical training, especially for clinicians who do not specialize in hospice or palliative care.

Patients and families, likewise, can be reassured that the tool supports appropriate use of pain-relieving drugs—a sign of VITAS’ commitment to serve as careful stewards of patients’ health. Patients’ personal information is protected as well. The app generates an email summary of the opioid conversion for the clinician-user but does not store patient data.

This hospice-specific opioid conversion tool continues and deepens VITAS’ standing as an industry leader in compassionate, data-driven, patient-centered hospice care. It will ensure that hospice patients receive the right medications in the right amount and right formulation for the right purpose: pain relief and ultimate comfort near the end of life.

Sepsis Linked to High Rates of Mortality, Rehospitalization Following Discharge

Thu, 16 Sep 2021 04:00:00 -0400

By Dr. Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

Hospitalized adults diagnosed with sepsis had higher rates of post-discharge mortality and readmission compared with non-sepsis patients, a population-based cohort study has found, indicating “the need for careful follow-up of severe sepsis survivors,” according to the authors of a report published in Critical Care Medicine.

“The results of this study highlight the high burden of sepsis,” the authors write. “We found that severe sepsis is associated with higher long-term mortality compared to non-sepsis hospital controls, even considering only the post-discharge period in hospital survivors.”

Investigators analyzed administrative health data collected by an independent research institute on 196,922 adult (aged ≥ 18 years) sepsis patients hospitalized in Ontario, Canada, between 2012 and 2016, with a median follow-up of 2.0 years (mean, 2.1 years; range, 1 day to 5 years).

Results indicate the need for careful follow-up of severe sepsis survivors.

The sepsis patients were stratified into groups of either severe sepsis (sepsis or infection with organ dysfunction or septic shock, 32.6%; n = 64,204) or non-severe sepsis (sepsis or infection without organ dysfunction, 67.4%; n = 132,718) and were propensity matched to non-sepsis controls.

During the 4-year period, 14.5% of patients admitted to hospitals in Ontario—which has a population of more than 13 million—were diagnosed with sepsis or infection, and 4.9% had severe sepsis. Sepsis patients overall had higher death rates during follow-up than patients in the non-sepsis control group (severe sepsis: 54% vs 36.2%; non-severe sepsis: 40.1% vs 31.7%).

Mortality

Overall, patients with severe sepsis had higher relative mortality rates compared with controls (22.3% vs 12% 0-30 days from admission; 17.4% vs 10.2% 30-183 days from admission; 8.5% vs 5.5% 6-12 months from admission).
Severe sepsis patients had the highest relative mortality rates at 0-30 days following discharge (22.3%). Cumulative mortality rates rose to 39.7% at 6 months; 48.2% at 1 year.
While patients with non-severe sepsis had lower mortality rates than controls at 0-30 days post-hospitalization (8.3% vs 9.9%), their relative rates were higher at 30-183 days (11.1% vs 8.7% [cumulative 19.4% vs 18.6%]) and 6-12 months (6.8% vs 4.6% [cumulative 26.2% vs 23.3%]).

Readmission

Sepsis patients overall had higher rehospitalization rates compared with controls (severe: 62.2% vs 48.4%; non-severe: 60.1% vs 47.1%).
Higher relative rates of rehospitalization were found among both severe (HR, 1.53; 95% CI, 1.50-1.55) and non-severe (HR, 1.41; 95% CI, 1.40-1.43) sepsis patients.
At both 30-day and one-year follow-up, severe sepsis patients had higher relative rates of rehospitalization (14.4% vs 9.4% at 30 days; 45.7% vs 32.2% at 1 year).
Non-severe sepsis patients also had higher relative rates of rehospitalization at 30-day follow-up (12.1% vs 9.1%) and one-year follow-up (41.5% vs 30.4%).

The research team concludes, “Severe sepsis was associated with substantially higher long-term risk of death, rehospitalization, and healthcare costs, highlighting the need for effective post-discharge care for sepsis survivors.”

More than one-third of severe cases die within 6 months of initial admission, making hospice an ideal option for sepsis patients seeking symptom management at home. Hospice offers both patient and family the support of an interdisciplinary team capable of administering complex modalities in any setting, while also reducing hospitals’ resource burdens related to readmissions and length of stay.

Source: Farrah, K., McIntyre, L., & Doig, C.J. (2021). Sepsis-associated mortality, resource use, and healthcare costs: A propensity-matched cohort study. Critical Care Medicine, February 1, 2021; 49(2):215-227; DOI: 10.1097/CCM.0000000000004777.

The Case for Timely Referral to Hospice

Tue, 31 Aug 2021 04:00:00 -0400

Timely referrals to hospice leave families more satisfied with their loved one's care while also decreasing unnecessary hospitalizations and lowering healthcare spend, recent studies show.

Still, Trella Health reported that only about 7% of hospice-eligible patients received an early referral to hospice. When contrasted with the Kaiser Family Foundation’s findings that 85% of Americans who have heard of hospice hold a positive opinion about it, clinicians and healthcare professionals are left to reconcile a considerable gap between the kind of care patients want and the care they’re actually receiving.

It’s a gap that can be closed when healthcare professionals make timely referrals to hospice for patients whose life expectancy is 6 months or less.

Higher Satisfaction when Hospice Patients are Referred Sooner

The core services of hospice are robust yet surprisingly simple to understand: An interdisciplinary team of clinical experts supports a patient’s and family’s personal goals for care near the end of life, ensuring their physical, psychosocial, and spiritual needs are met.

Likewise, it’s easy to grasp how this model benefits patients and families seeking help through one of life’s most challenging periods. The benefits of hospice have been studied and quantified for decades.

A 2017 report in the Journal of Clinical Oncology demonstrated that family members of patients receiving hospice care were more likely to express satisfaction with their loved ones’ symptom relief than relatives of nonhospice patients.

The report also found that earlier hospice referrals correlated with higher approval ratings from patients’ families.

Earlier Referrals to Hospice = Lower Healthcare Spend

These benefits extend to clinicians and other healthcare professionals. Data from a 2020 Trella Health study show how hospice patients—especially those referred to hospice early—face significantly fewer unnecessary hospitalizations and reduced healthcare spend compared to patients who did not receive hospice.

Related: Strong Hospice Presence in Nursing Homes Reduces Risk of End-of-Life Hospitalization >

An analysis of 904,000 patients who died between July 2018 and 2019 demonstrated that nonhospice patients accumulated six times the healthcare costs of patients in the early hospice admission cohort ($28,119 vs. $4,913).

Researchers examined costs across care settings, inpatient and ER utilization, and related metrics based on ICD-10-CM chapters. Patients were required to have at least one hospitalization in the year before their death. These patients were grouped into four cohorts based on their amount of time receiving hospice care:

Early hospice admission (≥3 months of care)
Medium hospice admission (2 weeks–3 months of care)
Late hospice admission (<2 weeks of care)
No hospice care

Key Findings

Patients who received early hospice care were 10 times less likely to be admitted to the hospital during their final month of life than their nonhospice peers.
When examining all terminal conditions, nonhospice patients took on an average of $27,455 more in healthcare costs than early hospice patients in the last three months of life.
Emergency room visits were 5 times more likely for late hospice patients than early hospice patients in the last month of life.

Hospice Patients Receive Care Where They Want It

The last point reflects a key point from the 2017 Journal of Clinical Oncology study: About 68% of hospice enrollees died in their preferred setting, compared to 39% of nonhospice patients.

A 2017 Kaiser Family Foundation study found that about 70% of Americans would prefer to pass away at home.

VITAS can provide high-acuity care and complex modalities to treat nearly any symptom in any setting, ensuring patients remain comfortable in a familiar place, surrounded by family who feel at peace with the care their loved one is receiving.

Physicians, nurse practitioners, and other healthcare professionals who care for patients with advanced illness can close this gap by referring to hospice as soon as they are eligible. VITAS makes it easy.

For starters, you can share the findings of the aforementioned studies with patients and families who may be unfamiliar with hospice and its benefits.

If you’re unsure whether a patient is ready for hospice, download a PDF of our disease-specific hospice eligibility guidelines.

Finally, when you’re ready to refer, VITAS is always available—24/7/365. Our compassionate, committed clinical experts are standing by to accept referrals, perform eligibility assessments, and transition patients to comfort-focused hospice care at any hour, including weekends and holidays.

Legacy of Love: Families, Culture, and Advance Care Planning

Mon, 16 Aug 2021 04:00:00 -0400

Dr. Illeana Leyva and Dr. Eric Shaban, VITAS regional medical directors, give a step-by-step demonstration of how to approach a goals-of-care conversation.

Coming to Consensus

Adult children and other family members bring their own fears and concerns about dying as they make decisions on their loved one’s behalf, says Jacob Huynh, MD, a VITAS physician in Orange County, California.

“Pause before providing unsolicited advice, especially prognostic advice.”-Adam Kendall, MD, VITAS medical review physician

In his primarily Vietnamese patient base, Dr. Huynh notices many families hesitate to wean their loved one from artificial nutrition, hydration, or antibiotics, even when doing so would contribute to a more comfortable death.

“Each patient and family has unique difficulties they have to overcome at the end of life, and we try to help them to successfully navigate this part of the journey,” he notes.

Dr. Huynh advises patients to “think more about what they want in advanced care, especially when they have multiple children who don’t always agree with the approach to care. That would make it easier when a life-threatening diagnosis arrives.”

Sunil Pandya, MD, associate medical director for VITAS in Naples, Florida, says even medical professionals can fail to find common ground in these contentious circumstances.

“My mother died in 2011 without hospice,” he says. “The family never had a good goals-of-care discussion, never had palliative care. My brothers and I were all well-educated—three of us in healthcare—but never came to a consensus on her care.”

Dr. Pandya attributes his choice to enter the hospice profession to this poignant end-of-life experience. A decade later, his father would die under his care at the VITAS inpatient unit in Collier County, Florida. The difference between the deaths was “night and day”: While his mother died in distress, alone in an ER without her family, his father was surrounded by loved ones who had time to physically, mentally, and spiritually prepare for the sad-but-unavoidable outcome.

“He couldn’t have had a more blessed ending to what was an eventuality that I couldn’t have changed,” Dr. Pandya says.

Leaving a Legacy

In some cultures, legacy and spirituality can intertwine. Tiffany Phuong, VITAS admission liaison in Orange County, California, says many older Vietnamese patients fear that dying at home could have a lasting impact on their successors.

“They’re afraid that if someone dies in the home, the spirit will remain in the home,” she says, “and some families may worry it will affect them when selling the home.”

These fears may be compounded by a patient’s or family’s concerns about those who are left behind, notes Dr. Kendall. Patients often find it easier to concentrate on someone who is not themselves, and “taking time to understand the family history or the virtues that help them be successful” is a key way to show respect to the patient and the family.

“Listen to understand who makes the life-changing decisions in the family and... pause before providing unsolicited advice, especially prognostic advice,” he says. “My own grandmother, a 106-year-old, at first struggled with incorporating a DNR and assisted home bathing. She now proudly speaks of how concerned she is of my aunt and uncle’s well-being.”

To Cultivate Trust, Start With a Conversation

When working with people of any cultural background, care professionals can cultivate trust and develop a deeper understanding of their patients’ needs by inquiring about relationship dynamics and family members’ concerns. Consider asking adult children about subjects their parent may find uncomfortable to discuss.

Goals-of-care conversations and advance care planning sessions offer natural starting points for discussing these topics, especially when family members attend.

Download our guide to goals-of-care conversations (PDF) for strategies on approaching complex issues with your patients and their families >

Mental Health Through Culture’s Lens

Wed, 23 Jun 2021 04:00:00 -0400

Palliative care and hospice clinicians face a considerable task: Assuage a patient’s pain, whether it comes from the body, mind, or spirit.

In the United States, most clinical training is devoted to the patient's physiology, leaving the rest of the wellness trinity to specialists—psychiatrists, psychologists, counselors, chaplains, and others.

A patient’s mental well-being, however, affects interactions with every member of the care team, regardless of their specialty or training. Any healthcare professional can improve these interactions and enrich their approach to care by learning not only how the patient feels psychologically, but also how they perceive their own mental health.

For most patients, their culture—a shared set of beliefs, norms, traditions, and values—is the primary lens through which mental health is viewed, defined, and even experienced. Culture can impact patients’ relationships with medical services and providers.

The clinician’s cultural identity plays a role too, influencing care from diagnosis to treatment and beyond.

Types of Pain Near the End of Life

The most commonly treated symptoms among palliative care patients are pain and shortness of breath, according to the World Health Organization.

However, psychiatric symptoms such as confusion, anxiety, and depression are often associated with physical distress. Clinical studies show that the areas of the brain that control emotions and the physical sensation of pain are altered in those who suffer from chronic pain.

Up to two-thirds of chronic pain patients also exhibit a psychiatric diagnosis.

Clinicians who are seeing a patient for overwhelming pain or breathing difficulty can provide more holistic care by asking how the patient perceives their own emotions, what they’re thinking, or how they would describe their mental health. The more the clinician understands about the patient’s culture, the better they can shape their questions, address specific concerns, and tailor care.

Why Are Mental Health Services Underutilized?

Culture shapes many aspects of mental illness, both as a social construct and as a set of diagnosable conditions. It seems to have an impact on the types of symptoms people experience and how they interpret those symptoms—certain conditions may even be specific to a single culture. It can determine if, how, and from whom people seek help, and whether they carry the burden of stigma when doing so.

In minority communities, mental health services often go underutilized compared with the general population. Black, indigenous, and people of color in America are less likely to seek out or receive mental health care, and more likely to receive poor care.

Adam Kendall, MD, medical review physician for VITAS in Orange County, California, attributes this disparity to two causes:

The secondary status of mental health in the managed health and public health system
A sense of shame associated with psychiatric care

In some cases, he says, psychological pain or distress is perceived as a shortcoming. Members of recently immigrated families, for instance, may feel that their mental illness threatens to undercut the achievements of previous generations.

“You strive to achieve or over-achieve to live up to the expectations of elders who brought you to the United States,” says Dr. Kendall, who is Japanese American. “There’s a sense of wanting to arrive at the success that took generations for your ancestors to achieve.”

Cultural Stigma and Expectation Surrounding Mental Health

Stigma surrounds mental illness in many cultures, and clinicians aren’t necessarily any more immune to it than their patients.

Dr. Kendall says many healthcare professionals struggle to meet their own psychological needs through self-care, though he acknowledges that the medical community is increasingly benefitting from an “evolving awareness of mental illness as a true disease.”

Hinduism and Death and Dying

Mythili Bharadwaj, MD, medical director for VITAS in St. Louis, Missouri, suggests that broader cultural philosophies can determine whether certain symptoms are considered worthy of treatment.

She recalls her childhood in India, the birthplace of Hinduism, and the interplay between Hindu ideals and healthcare norms: “Back then, when I grew up in India, anxiety and depression [for example] were not openly acknowledged as ‘medical conditions deserving medical attention.’ They were treated more as routine cycles in the journey of life.”

Dr. Bharadwaj highlights the Hindu concept of karma, a Sanskrit term that refers to work, action, or deed, and more broadly describes a spiritual cause and effect. (Karma is also a fundamental concept in other Asian religions, such as Buddhism, Sikhism, and Taoism, though its interpretation and function differ between and within each.)

Hindus, she suggests, may be more likely to see negative experiences—anxiety, depression, or other forms of suffering—as the result of one’s karma accrued in the past, or even in past lives.

Thus, certain experiences deemed “pathological” within the Western medical tradition may represent an intrinsic part of existence in Hindu culture, best overcome with hope, prayer, and spiritual resilience rather than medical intervention.

“Yes, pain is a natural part of life, but we also believe in the fact that better things are coming,” says Dr Bharadwaj.

Palliative care, she notes, has overcome some cultural stigma in India since her childhood, but is still relatively absent from the country’s rural regions. “My hope is that one day palliative care would be a global phenomenon and communities would progress enough to accept, adopt, and adapt such practices without guilt.”

5 Best Practices for Providing Culturally Sensitive Care

Wed, 26 May 2021 04:00:00 -0400

2. Listen, don’t assume

Whether or not you were involved with a patient’s GOC conversation, there’s always more to learn about their needs and preferences. Certain details might have been left out of an initial GOC discussion. Maybe the patient’s goals have evolved. Routinely ask the patient and their caregiver/family if you’re missing something, or if you could be doing anything to make their medical care align better with their ideal.

Knowingly or not, we all tend to have some preconceptions and biases about a patient’s ethnicity, age, national origin, gender, or religion. Limit your assumptions about how these factors affect a person’s preferences for care.Instead, use your existing knowledge to ask better questions. Then incorporate the answers into your care of the patient and their family, demonstrating that their needs and preferences are heard.

Bear in mind that the needs of the patient and the needs of the family may differ, requiring increased sensitivity when discussing care options.

“In many immigrant cultures... it’s not that hospice is quote-unquote taboo, it’s that they feel their culture is taboo to hospice,” says Sunil Pandya, MD, associate medical director in Collier County, Florida. “We don’t know if hospice knows what we want.”

“You have to personalize your touch,” he adds. “Take a barometer—not an assumption—of [the patient’s culture and spirituality].”

3. Research end of life cultural practices

Once you better understand who your patient is and have identified their preferences for care, do some additional research.

Consider how a patient’s generational status may intersect with their national origin or ethnic community. If you know your patient lived overseas when they were younger, look into the regional politics and major events of the time.

For instance: “In the Vietnamese community... most of the people came here from Communism. We never had this kind of service, so [hospice] comes across as too good to be true,” says Tiffany Phuong, admissions liaison in Orange County, California. “It just hasn’t been explained in the right way.”

Again, avoid making assumptions about an individual, no matter how well-informed or well-intentioned you are. With a little research, it’s easier to anticipate and address issues before they arise. Plus, your knowledge can help a patient feel confident in what they might otherwise see as a risky decision to elect hospice care.

Dr. Marwah refers to this approach as “answering the telephone before it rings.”

“You know the ethnicity of this family, you know their religion. When we get these patients on our service,” he says, “it is paramount that we take all of those things into account and assure patients and families that their needs will be met.”

4. Seek support when you need it

While you’re likely able to perform many parts of your role without assistance, it’s OK to ask for help if you feel overwhelmed.

If you’re facing a language barrier, see if a member of your organization can help translate. For instance, VITAS offers a translator service for all members of its staff.

If a patient seems hesitant to discuss certain needs with you, consider inviting another member of your team to be present during a visit. You might even reach out to a local medical association or cultural organization for guidance. In some cases, patients may be more willing to open up to someone who feels familiar to them.

“Diversity in hiring is obviously important,” says Robert Nguyen, medical director in Orange County. “Having someone of the same or similar ethnic or religious background can help lay the foundation for trust in the relationship. Many patients and families appreciate being able to relate to staff culturally and spiritually.”

5. Accommodate wherever possible

When discussing care options with patients near the end of life and their families, you must embrace the needs of people and cultures who may be unfamiliar with the benefits of hospice and palliative care, rather than expecting them to adapt to the standards you’ve long maintained. In certain parts of the world, comfort care is associated with poorly maintained facilities or places where the elderly are left to die. In others, this sort of care is nonexistent.

Think about all the ways, small and large, that you can make a difference for a patient and their family during every visit. Consider how you can change your approach to care to help a patient feel seen, understood, and honored. Practice patience during uncomfortable conversations, and always seek opportunities to learn more about the patient’s needs through questions and observation.

“When we show that hospice can be sensitive to these needs, not only are we helping families make the right decision, but we’re creating partners who can go back into the community to talk about the benefits of our services,” says Dr. Marwah. “I tell my team all the time, these families are ambassadors for hospice.”

Pain’s Culturally Defined Role in Dying

Wed, 16 Jun 2021 04:00:00 -0400

Comfort and dignity are two of the primary goals of every hospice and palliative care plan. For most patients, pain management is integral to success.

Every patient experiences pain in their own way, so clinicians must consider unique physiological and psychosocial factors like the patient’s:

Specific illness
Physical state
Cognitive and psychological state
Drug allergies and interactions
Personal tolerance for discomfort

Culture is a less-considered but crucial element of the individual pain experience. Culture can impact a patient's relationship with pain in surprising ways, from the sensation of pain itself to a patient’s willingness to communicate what they’re feeling.

Likewise, clinicians’ own beliefs and traditions can influence how they perceive, understand, and treat pain. Caring for patients whose cultural attitudes toward pain differ from one’s own presents a potential challenge—but also an opportunity for humility, learning, and growth.

“Cultural sensitivity is really important. People bring with them a whole story,” says Preeya Desh, MD, a hospital-based palliative care physician for VITAS Healthcare in West Palm Beach, Florida. “Coming at it with a lens that ‘this is how we do it here’ isn’t helpful for anyone. You’re talking two different languages.”

Cultural Influences on Pain

Hospice and palliative care clinicians know that the level of pain patients express does not always reflect what they're feeling. Some patients might not even recognize certain sensations as pain—or, at least, pain worthy of noting—based on their understanding of what’s “normal.” Culture can contribute to these expectations.

“’Take what comes’ is what we’ve been taught.”-Mythili Bharadwaj, MD, VITAS medical director

“In a lot of Asian cultures, the idea of suffering is accepted,” says Dr. Desh, who grew up in the US and attended medical school in India. “You’re asked to be a little more stoic, you’re expected to bear a certain level of pain.”

Deep-seated philosophical or religious beliefs also can explain certain cultural norms about pain and suffering. For instance, modern Christians, Jews, and Muslims have varying ideas about the origin and purpose of pain, but they generally believe in a common duty to relieve suffering where it exists. Some Hindus and Buddhists attribute an individual’s present suffering to karma—the accumulated moral value of a person’s actions across current and past incarnations—while others chalk it up to material attachment, or the will of a God or gods.

Resource: 5 Best Practices for Providing Culturally Sensitive Care >

Mythili Bharadwaj, MD, medical director for VITAS in St. Louis, Missouri, shares a cultural insight from her upbringing in India, a predominantly Hindu nation: Pain and misfortune in the present moment will pass, and those who are suffering often presume that “better things are coming.”

“It’s a culture we’ve been raised in and grown into,” she says. “’Take what comes’ is what we’ve been taught.”

Seeking Relief – or Not

A society’s material resources and medical infrastructure can influence cultural expectations about pain—and trust in pain management—as much as any belief system.

Munima Shaikh, MD, a palliative care physician for VITAS in Orlando, Florida, shares why Pakistani patients in the US might not seek out pain relief intuitively.

“We really don’t have much palliative care in Pakistan. Most patients who are seriously ill go home and die with their families,” says Dr. Shaikh. “We don’t have a lot of resources like pain medicine. Morphine is not widely available outside of major surgical hospitals.”

In parts of the world where the hospice and palliative care disciplines are still developing, confusion and uncertainty may surround comfort-focused care, limiting usage by potentially eligible patients.

For example: “There’s a taboo associated with morphine [in Pakistan],” Dr. Shaikh says. “Pain medicine is associated with dying. That part is difficult to navigate, but once you explain it, it’s often fine.”

The Taboo of Death

Even veterans of comfort-focused care can feel uncomfortable discussing death, yet in certain cultures, the topic carries additional weight. Dr. Bharadwaj grew up in India, where death is an especially difficult subject. “Like in any close-knit society... it is a taboo to talk about dying,” she says. “This is where cultural sensitivity and cultural competence play a role.”

“Pause before providing unsolicited advice, including prognostic advice.”-Adam Kendall, MD, medical review physician

Cultural norms about elders can also complicate decisions about palliative care. Adam Kendall, MD, medical review physician in Orange County, California, has learned plenty about these subtle communication preferences from his experiences with Asian patients and families, and from his own Japanese American heritage.

“The Asian elder can delegate complex decision-making to a family member... or they may not wish to ever hear about the prognosis. They may feel it’s an act of shame to openly talk in their presence about the end of their life,” he says. “They may also prefer to focus on the aspects [of the end of life] that have to do with family wealth, or support of the next generation, and that may be foreign to the medical team.”

Dr. Kendall offers some advice worth considering before initiating a goals-of-care conversation, whether or not taboos are a concern:

“The best way to approach [cultural] barriers is to take the time to listen and understand who makes the life-changing decisions in the family,” he says, “and to pause before providing unsolicited advice, including prognostic advice.”

‘Clashing of Two Cultures’

Certain kinds of pain or distress may be treated as personal shortcomings among members of some immigrant communities, especially when stoicism and self-sufficiency are measures of success, notes Dr. Kendall.

He recalls encountering these perceptions both at home and within the medical community while seeking support for the depression faced by his late wife and fellow physician, Dr. Normy Chiou:

“She was a shining example of what some Asian Americans can overcome despite the clashing of two cultures. While she couldn’t share her illness very openly with family, she grew to understand the reasons underlying the high expectations and fear of shame. You strive to achieve or over-achieve to live up to the expectations of elders who brought you to the United States. There’s a sense of wanting to arrive at the success that took generations for your ancestors to reach.”

Overcoming with Culturally Sensitive Outreach

In the United States, the population of older (age 65+) people of color is growing rapidly, yet they are less likely than non-Hispanic whites to receive hospice care at the end of life, according to the National Hospice and Palliative Care Organization. Barriers to access are varied and complex: distrust of healthcare institutions, lack of local providers, and misunderstanding of or unfamiliarity with services represent just a few.

“You need to build that trust in the whole community.”-Patty Wu, MD, VITAS medical director

Providers can employ culturally sensitive outreach to overcome these issues, working with physicians and other trusted members of immigrant communities, minority religious organizations, and culturally specific medical associations to share information about the benefits of their services.

Tiffany Phuong is a VITAS representative on an all-Vietnamese team in Orange County, California. After speaking to a variety of groups and individuals in person, online, on television, and over the radio, she’s found that every educational opportunity has the potential to open doors to another.

“People come to one meeting and they think it’s very helpful, and then they invite me to their own group,” Tiffany says. “I want to help people to recognize how important that is. When I started 10 years ago, we hardly had Vietnamese patients. One positive experience brings others to us.”

People who feel their concerns are heard, and who understand how hospice and palliative care can address those concerns, are more willing to take a chance on an otherwise unfamiliar approach to care. Tiffany isn’t the only one to think so.

“The expectation [in some Asian cultures] is that we take care of our own, we don’t need someone coming into our house,” says Patty Wu, MD, medical director for VITAS in San Gabriel, California. “You need experience to take that leap of faith. You need to build that trust in the whole community, and that takes volume.”

‘We Need to Go in Without Bias’

According to Dr. Wu, the best hospice and palliative care advocates are patients and families who are willing to share their positive experiences within their own communities, using the familiar languages and terms of their cultural peers.

To produce these experiences, clinicians need to consider a person’s cultural perspective without relying on stereotypes or assumptions, approaching each patient first and foremost as an individual.

“There’s a broad conversation and exploration that has to happen [that involves] asking patients about their beliefs on an issue,” says Dr. Desh. “We need to go in without bias and paternalism. Suffering is a relative term, and as a physician, I need to honor that.”

An Effective Tool Against COVID-19: Vaccine Education

Tue, 24 Aug 2021 04:00:00 -0400

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

Throughout the last half of 2021, he US has experienced a dramatic increase in COVID-19 cases, hospitalizations, and deaths secondary to the delta variant of the COVID virus.

The best tools to overcome any health challenge are evidence-based data and informed guidance from medical professionals.

Both are available in this training presentation from VITAS Healthcare about COVID-19 and the vaccines that combat it.

VITAS is offering this presentation for partner organizations to use for their own in-house or staff training. For your employees, partners and members of the public, the presentation describes:

How the vaccines were developed
The safety protocols that are deployed for all vaccines
How vaccines work to trigger antibodies
Common side effects of vaccines
Information to combat vaccine misconceptions
Who should and should not receive the vaccine, and the various reasons why
The vaccine’s ability to reduce the likelihood of hospitalization and death from a “breakthrough” infection in a vaccinated individual
CDC vaccination recommendations for pregnant women and those thinking about becoming pregnant
CDC guidance on now-recommended “booster” shots for vaccinated individuals 8 months after their initial vaccination series
Vaccine recommendations for people who have already contracted COVID-19

Millions of people in the United States—more than 50% of the population—have received COVID-19 vaccines under the most intense safety monitoring in US history. The vaccine protects you, your patients, friends, families, and others.

Moreover, COVID-19 vaccines are highly effective against the delta variant: 88% effective against symptomatic disease and up to 96% effective against hospitalization. As such, vaccines remain our best defense against COVID including symptomatic disease, hospitalizations, and death.

As vaccines roll out across the US and the rest of the world, they have become increasingly required for employees in key positions and professions, including healthcare and patient-facing roles. Likewise, vaccines are now required for some other common activities, including international travel, cruises, indoor concerts, in-person college attendance, a growing number of workplaces, and other events where large numbers of people gather.

Most importantly, the best, quickest, and safest path back to a normal life is for everyone to do their part and get vaccinated.

Hospice and Palliative Care Needed for Dementia Patients and Caregivers

Thu, 29 Apr 2021 04:00:00 -0400

The symptom management and support provided by palliative care are important for preventing and relieving suffering for family caregivers and patients with dementia, according to an American Journal of Geriatric Psychiatry article by psychiatry, geriatrics, and palliative medicine specialists.

The authors call dementia “a life-altering illness for families and a life-limiting illness for patients.”

They intend their article to assist clinicians in applying key elements of palliative principles in the care of their dementia patients, and to encourage the “use of both palliative care and hospice services as an extra layer of support for the providers, patient, and family, preferably sooner in the disease course rather than later.”

Elements of an approach to managing neuropsychiatric symptoms include:

Whole-person care
Accurate diagnosis
Categorization of symptoms and behavior
Nonpharmacologic interventions
Clear communication regarding the use of any psychoactive medications
“Care for the patient and family across all domains of potential suffering”

The authors also stress the importance of pain assessment and advance care planning in the care of patients with dementia, as supported by the American Academy of Neurology’s updated 2017 Dementia Management Measurement set.

Depression in Partner Caregivers of Dementia Patients Increases Over Time

Older adult caregivers of their spouses/partners with Alzheimer’s disease and related dementias (ADRDs) report a higher number of depressive symptoms than their cohorts whose partners do not have dementia, and these depressive symptoms increase over their years of caregiving, according to a study in the Journal of Applied Gerontology.

Investigators analyzed data collected by the National Institute on Aging’s Health and Retirement Study in two-year increments from 2000 to 2014 on a nationally representative sample of 16,650 respondents aged ≥ 51 years (mean age, 65.6 years) and their partners.

Key Findings

Compared with respondents whose partners had no ADRD, respondents with partners diagnosed with ADRD had a 30% increase in reported depressive symptoms from baseline to follow-up.
Respondents whose ADRD partners were diagnosed within 2 years showed a 27% increase in depressive symptoms.
Those whose partners were diagnosed more than 2 years ago reported a 33% increase in depressive symptoms.

“In all, the effects of an ADRD diagnosis are sizable and grow over time,” write the authors. Substantial research has identified “shared trajectories of health” among older adult dyads, including dementia caregivers and their care recipients, they note. The growing emotional cost of helping a partner with a progressive disease such as dementia reinforces the need to “‘care for the caregiver’ as behavioral and care needs exacerbate over time.”

Sources:

Irwin, S., Shega, J., & Sachs, G. (2018). The Importance of Palliative Care for Dementia. American Journal of Geriatric Psychiatry, 26(2):235-237; DOI: 10.1016/j.jagp.2017.08.010.

Harris, M., Titler, M., & Hoffman, G. (2020). Associations Between Alzheimer’s Disease and Related Dementias and Depressive Symptoms of Partner Caregivers. Journal of Applied Gerontology, Epub ahead of print, DOI: 10.1177/0733464820952252.

The True Benefit of Palliative Care

Wed, 28 Oct 2020 04:00:00 -0400

If physicians or specialists do not feel comfortable with these difficult-but-rewarding conversations, trained VITAS facilitators are always available to meet with patients and families—wherever they are and whenever they are ready to decide the course of their care as their health declines.

VITAS Can Help You Educate Your Patients

Just as we can help physicians overcome their unease or perceived lack of training to engage in goals-of-care conversations, we can help patients overcome their concerns about the transition to hospice care, by:

reassuring patients that hospice care does not mean giving up the medications or treatments (e.g., inhalers, access to a respiratory therapist) that currently provide comfort and symptom management
explaining the value of the interdisciplinary hospice team to address physical, emotional, and spiritual needs
offering an individualized care plan and one of four levels of hospice care to meet their individual needs and goals
adjusting medication delivery seamlessly as their symptoms worsen to maintain comfort (e.g., switch from inhaled medication to nebulized versions in the home)
delivering the necessary equipment, medications, and supplies directly to them, wherever they prefer to receive care, usually at a cost saving
easing the concerns of anxious family members and caregivers through regular team visits, training, educational materials, and 24/7 availability of VITAS clinicians to manage crises and keep their loved one comfortable

Goals-of-Care Conversations Should Be Commonplace

Our goal is to support our healthcare partners in private practices, specialty practices, hospitals, and care facilities. We want them to embrace a 360-degree view of advanced disease so that they know when it’s time to call VITAS for a goals-of-care conversation. Ideally, suggesting a GOC conversation should be as commonplace in a clinician’s daily routine as taking vital signs, interpreting laboratory findings, and exploring treatment options, particularly for those with advanced illness.

What are signs of hospice eligibility in a patient with advanced lung disease?

A “no” answer to the “surprise question”: “Would you be surprised if this patient were to die in the next year?”
Shortness of breath at rest or with minimal exertion
More than 50% of waking hours spent sitting or resting (Palliative Performance Scale of about 50%)
More dependence for activities of daily living
Functional decline over time

We know that talking with patients about their disease and wishes is one of the hardest—and most important—activities that healthcare professionals can undertake, especially for patients with advanced illness.

Just as our hospice care teams and on-call clinicians are available 24/7/365 to provide end-of-life care, our trained physicians, nurse practitioners, and social workers are always available to start the conversation about the transition to comfort-focused care.

Palliative Care ‘Void’ Deprives ALD Patients of Proven Beneficial Care

Wed, 11 Oct 2023 04:00:00 -0400

Palliative care can improve symptoms, patient satisfaction, and quality of life in patients with end-stage disease, yet it remains “a void that needs filling” among patients with advanced lung diseases, according to an article published in the Annals of the American Thoracic Society.

The two most prevalent end-stage lung diseases are lung cancer and chronic obstructive pulmonary disease (COPD), the latter of which was the third leading cause of death in the United States prior to the COVID-19 pandemic and the fourth-leading cause of death worldwide. (The two leading causes of death are heart disease and cancer.)

Hospice Eligibility Guidelines for Advanced Lung Disease & COPD >

Even as treatment of COPD evolves, patients living with this incurable, progressive disease have a heavy symptom burden, including dyspnea, fatigue, cough, and pain. This burden often remains unaddressed at the end of life, write co-authors Rosechelle Ruggiero and Lynn F. Reinke.

“…Strong evidence exists supporting the benefits of integrating palliative care into routine care for persons diagnosed with advanced lung diseases.”-Lynn F. Reinke, PhD, ARNP, VA Puget Sound Health Care System

Patients’ quality of life is also significantly impacted by anxiety—which ranges from 20% in patients whose COPD is stable to 75% in those with severe airflow limitation—and by depression, which averages 40% in all stages of the disease and is greater than 60% among patients requiring supplemental oxygen.

Despite having a higher reported symptom burden than patients with other advanced chronic conditions, less than 15% of COPD patients receive palliative care, according to recent research, with many experiencing high-intensity care as the end of life approaches.

“Patients with COPD are more likely to die in the intensive care unit than patients with lung cancer and are also more likely to receive aggressive measures such as mechanical ventilation at the end of life,” according to Ruggiero and Reinke.

Palliative care is much more than end-of-life care. Palliative care is a clinical specialty that focuses on maximizing a seriously ill patient’s comfort and quality of life. It is therefore appropriate at any point during the COPD trajectory.

Ideally, palliative care should begin before the patient has experienced a significant decline in their well-being or functional status. Palliative care is not synonymous with hospice or end-of-life care—palliative treatments may begin at the time of diagnosis with any serious illness and can continue concurrently with illness-directed therapies.

Benefits of Palliative/Hospice Care

Recent studies found improvements in symptom burden and quality of life in COPD patients—and their family caregivers—with the initiation of palliative/hospice care provided by a multidisciplinary team whose goal is to prevent and relieve suffering, and “attain the best possible quality of life” for those in its care.

Palliative/hospice care provides:

Management of pain and other physical and psychological symptoms
Goals-of-care discussions, individualized to align treatment with patient preferences and values
Coordination and communication between patients and those involved in their care

Initiating palliative solutions into COPD patients’ care plans has also been shown to significantly decrease healthcare system costs, note the authors. “In addition, and more important(ly), patients have a better quality of life when palliative care services and end-of-life discussions are implemented in a timely fashion,” they write.

Barriers to referral to palliative/hospice care include:

Limited availability of palliative care specialists
Lack of clinician training in primary palliative care
No established “trigger” for palliative or hospice care involvement
Clinician hesitancy in initiating goals-of-care and end-of-life discussions
Prognostic uncertainty in COPD

“However, discussions about end of life and advanced care planning should not hinge on this prognostic uncertainty,” write the authors, “and these needs can and should be addressed at any time. Many palliative care experts recommend that clinicians start to broach end-of-life discussions at the time of diagnosis.”

This article was originally published in October 2020 and updated in October 2023.

Source: Ruggiero, R., & Reinke, L.F. (2018). Palliative Care in Advanced Lung Diseases: A Void That Needs Filling. Annals of the American Thoracic Society, 15(11):1265-1268. DOI: 10.1513/AnnalsATS.201805-347HP

Hospice Provides Post-Discharge Support That Sepsis Patients Need

Tue, 28 Jul 2020 18:46:00 -0400

More Help: How to Talk About Hospice Care >

Those of us in hospice are working hard to bridge the gap, but even as our healthcare system transitions to a value-based model, the mentality of fee-for-service still permeates our nation’s acute-care facilities, and many hospitalists see a discharge home as a success.

Hospice: A New Way Of Judging Success

In hospice, we judge our successes on the patient’s quality of life and the fulfillment of their goals and wishes near life’s end. Usually, that means going home with 24/7 support from an interdisciplinary hospice team. Whether home is a traditional residence, an assisted living facility, or nursing home, the hospice team will assist caregivers (and/or facility staff) with direct clinical care and education, integrative services, bereavement support, and delivery of medication, equipment, and supplies.

In other cases, improving quality of life means remaining in a general inpatient setting with hospice support, taking the burden off hospital staff until the patient is able to transition home or until the patient dies. Hospice offers complex modalities in any setting, so patients who would otherwise be confined to an ICU can usually return home to be among loved ones.

With support from hospice, a sepsis patient and their family are more likely to report higher satisfaction of care and greater quality of life. The patient’s emotional and spiritual needs can be met alongside their physical needs, thanks to care from chaplains, social workers, music and massage therapists, and other integrative specialists. Finally, the patient is more likely to die at home, surrounded by loved ones, rather than in the hospital.

Because sepsis is most common in patients with advanced or chronic diseases that indicate hospice eligibility, acute incidences of sepsis should always trigger a hospice eligibility assessment. We owe it to our patients, their loved ones, and our colleagues in healthcare, all of whom can benefit from the support that timely end-of-life care offers.

After Sepsis Hospitalization, Elevated Biomarkers Linked to Readmission and Death May Persist

Tue, 28 Jul 2020 18:47:00 -0400

Two-thirds of sepsis survivors were found to have persistent elevated circulating biomarkers for both inflammation and immunosuppression, with a higher risk of readmission and mortality—particularly due to cardiovascular disease and cancer—compared with patients with normal biomarkers in the year following the index hospitalization, according to a report in JAMA Network Open.

“Persistent elevation of inflammation and immunosuppression biomarkers is common up to a year ... and may be associated with poor long-term outcomes.”-Sachin Yende, MD, MS, Deputy Chief of Staff, Veterans Affairs Pittsburgh Healthcare System

“The dysregulated host immune response activated during sepsis may persist up to one year,” write the authors. “Our findings suggest that long-term immunomodulation strategies should be explored in patients hospitalized with sepsis.”

Investigators analyzed data collected via bedside assessments, home interviews, and medical records on 483 adults (mean age, 60.5 years; male, 54.9%; white, 82.2%) hospitalized for sepsis in one of 12 U.S. hospitals across eight states from 2012 to 2017.

Post-discharge follow-up included measurements at three, six, and 12 months of circulating biomarkers of pathways activated during sepsis: inflammation, immunosuppression, hemostasis, endothelial dysfunction, and oxidative stress.

Overall

77.8% of sepsis patients had at least one chronic disease.
88.4% were discharged to home; 11.6%, to a long-term care facility.
42.5% were readmitted during the following year, with 31.7% of those being readmitted ≥ 3 times. Median time to first readmission was 63 days.
8.9% had died by three months; 11.6%, by six months; 17.6%, by 12 months.
Common causes of death included cancer (46.4%), infection (23.2%), and cardiovascular disease (17.4%).

Key Findings: Biomarkers

Elevated inflammation markers were observed in 25.8% of patients at three months; in 30.2% at six months; and in 25.6% at 12 months.
Elevated immunosuppression markers were seen in 46.4% of patients at three months; in 44.9% at six months; and in 49.4% at 12 months.
Based on these trajectories, two common phenotypes were identified: hyperinflammation and immunosuppression phenotype (68.3% of patients) and normal phenotype (29.6%).

Patients with the hyperinflammation and immunosuppression phenotype had similar clinical characteristics, in-hospital course, age, chronic disease burden, and illness severity compared with patients with the normal phenotype.

Phenotypes and Outcomes

Compared with normal phenotype, patients with the hyperinflammation and immunosuppression phenotype had higher:

One-year mortality (odds ratio [OR], 8.26; 95% confidence interval [CI], 3.45 to 21.69; P < 0.001)
Six-month all-cause readmission or mortality (hazard ratio [HR],1.53; 95% CI, 1.10 to 2.13; P = 0.01)
Six-month readmission or mortality attributable to cardiovascular disease (HR, 5.07; 95% CI, 1.18 to 21.84; P = 0.02)
Six-month readmission or mortality attributable to cancer (HR, 5.15; 95% CI, 1.25 to 21.18; P = 0.02)

Source: Yende, S., et al. (2010). Long-term host immune response trajectories among hospitalized patients with sepsis. JAMA Network Open, 2(8):e198686. DOI: 10.1001/jamanetworkopen.2019.8686. Veterans Affairs Pittsburgh Healthcare System; Clinical Research, Investigation, and Systems Modeling of Acute Illness Center; and Center for Critical Nephrology, Department of Critical Care Medicine, University of Pittsburgh, all in Pittsburgh, PA.

Sepsis Patients Face Poor Healthcare Trajectories Following Hospitalization

Tue, 28 Jul 2020 18:47:00 -0400

Medicare beneficiaries hospitalized with sepsis, whether the condition was present on admission or acquired during hospitalization, are at increased risk for worsening health and death, and have greater use of advanced healthcare services and less likelihood of being discharged to home compared with non-sepsis patients, according to a report published in Critical Care Medicine.

“Once sepsis is established, improving the immediate post-sepsis trajectory…appears to be an essential step toward value-based transformation of sepsis care.”-Timothy G. Buchman, PhD, MD, U.S. Department of Health and Human Services

“The trajectories of beneficiaries subsequent to a sepsis inpatient admission contrast sharply with those admissions that do not include sepsis,” write the authors. “Despite seemingly successful treatments of infection and organ dysfunction, sepsis survivors frequently fail to fully recover their health and their prior quality of life.”

Hospice and Sepsis: Guidelines for Eligibility >

Investigators analyzed Medicare claims data for patients admitted to all U.S. acute care hospitals with sepsis (n = 69,401) and without sepsis (n = 613,395) in January 2017. They first reviewed diagnostic, procedure and encounter codes for the year prior to admission. Next, they compared healthcare services used in the week prior to admission by all sepsis inpatients with all non-sepsis inpatients admitted from 2012 to 2017, then compared the subsequent health trajectories of the two groups.

Findings: One Year Prior to Admission

Researchers found no discernible differences and “no particular predictive insight” about the two groups when they compared the 10 most prevalent chronic conditions among the non-sepsis patients who had been admitted to the hospital prior to January 2017 to the patients who were admitted and developed sepsis.

However, the top discriminant diagnosis for sepsis admission was “other sepsis.” Sepsis had occurred earlier (in the previous year) in about 10% of patients with a current sepsis-coded admission, a percentage that was 3.5 times higher than the rate among patients with no sepsis during the index hospitalization.

Among patients with no hospital admissions in the prior year, those whose inpatient stays included a sepsis code, compared with patients with no sepsis, had:

More than three times as many deaths within one week of discharge
More admissions to skilled nursing facilities (SNFs) and fewer discharges to home

Findings: One Week Prior to Admission

Claims for services in nursing facilities in the week prior to admission were 2.5 times higher among patients with subsequent sepsis admission, suggesting that recent use of skilled or unskilled nursing care was a strong indicator of patients being destined for sepsis admission.
15% of patients with septic shock had inpatient claims for sepsis in the week prior, as did 10% of those with other severities of sepsis.

Overall, the percentage of sepsis admissions increased from 2012 to 2018—particularly among patients with sepsis present on admission—while the non-sepsis admissions decreased during that time.

Further, sepsis admissions also accounted for a rising percentage of long inpatient stays, while the percentage of long stays for non-sepsis patients declined.

Six-Month Trajectories Following Index Admission

Discharged to a personal home: 57.2% sepsis vs 79.8% non-sepsis
Died: 32.6% vs 13.3%
Transferred to a nursing home: 5.0% vs 2.8%
Transferred to a SNF: 2.3% vs 1.7%
Transferred to a hospice facility: 1.8% vs 1.4%

Among all patients admitted to a SNF subsequent to discharge, those with sepsis were more likely than those with no sepsis to:

Die in the SNF
Be readmitted to an acute-care hospital and die in that setting
Go next to a custodial nursing home if they had survived to discharge from the SNF

“All sepsis admissions are not the same,” note the authors. Patients with septic shock are more likely to die in the hospital and less likely to reach a SNF. Only 36% return home within six months. Further, while 54% of patients with sepsis diagnosed on admission returned home within six months, only 32% of those with sepsis diagnosed while an inpatient did so.

Source: Buchman, T.G., et al. (2020). Sepsis among Medicare beneficiaries: 2. The trajectories of sepsis, 2012-2018. Critical Care Medicine, 48(3):289-301.Biomedical Advanced Research and Development Authority, Office of the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human Services, Washington, DC; Emory Critical Care Center, Emory University, Atlanta; Center for Medicare and Medicaid Services, U.S. Department of Health and Human Services, Baltimore.

Grief and Loss Among Healthcare Workers

Tue, 26 May 2020 20:30:00 -0400

By Robin Fiorelli, Senior Director of Bereavement and Volunteer Services, VITAS Healthcare

From the moment the first US coronavirus patient was diagnosed, front-line healthcare workers in all roles and across all 50 states have faced tremendous personal and professional challenges. Against all odds, you have rallied to help, and many of you now experience very real feelings of grief, loss, doubt, and anxiety.

Understanding colleagues are ready to listen to your stories, identify your challenges, and find resources to help you cope.

Others Share the Same Stresses and Sources of Grief

First, know that you are not alone in your experiences and that help is available.

Daily, you have put your own health at risk and returned to stressful working conditions in busy hospitals, emergency departments, and care facilities. You have faced scenarios unlike nearly anything in modern healthcare history. Despite your best intentions and efforts, many of your patients, residents, and even your coworkers have died.

Perhaps you’ve stood as a surrogate or substitute family member at a patient’s or resident’s deathbed. Maybe you now question your abilities and skills as a healthcare professional. You might be worried, anxious, and exhausted. Like the rest of the country, you are likely fearful or unsettled about what the future holds.

Look for Common Behaviors and Symptoms of Grief, Stress, and Anxiety

If you’re a healthcare worker in any role, look for symptoms, emotions, and behaviors that indicate the time is right to initiate self-care, talk to someone, or reach out for help.

Physical Reactions

Tightness in the chest or a sensation of not being able to breathe
Muscle tension, aches, pains
Headaches
Restlessness, inability to relax, difficulty sleeping
Heart palpitations
Digestive issues

Emotional/Behavioral Reactions

Anxiety, worry, and fear about getting sick/infected or infecting others
Anger and frustration (at the virus, sheltering in place, disconnection with loved ones/routines, unemployment, loss of income, etc.)
Sadness or crying more than usual
Insomnia, strange dreams
Exhaustion
Change in eating behaviors (eating more or less)
Trouble staying focused
Aggravation of pre-existing medical or psychological conditions

Find Ways to Support Yourself and Connect With Others

Next, take time—even if only a few minutes a day—to care for yourself.

Stay updated about the pandemic from trusted sources and in increments that do not add to your anxiety or distress.
Identify and share COVID-19 facts so you understand actual risks to yourself and the people you care about.
Talk to others to decrease your isolation/loneliness and to establish sources of support. Keep in touch with loved ones, family, and friends via phone, text, and virtual platforms.
Remind yourself that you are resilient. Rely on coping strategies that have worked in the past to calm and address your concerns, including faith, positive self-talk, exercise, friends, support groups, hobbies, yoga, mindful meditation, good nutrition, etc.
Stay in the present and take one day at a time.
Avoid “what-if” thoughts, mental worst-case scenarios, alcohol, tobacco, or other drugs.
Monitor yourself for symptoms of depression or extreme anxiety: prolonged sadness, difficulty sleeping or over-sleeping, intrusive thoughts or memories, hopelessness, inability to function.
Talk to a peer or supervisor, or seek professional help if needed. Focus equally on solutions and frustrations.
Give compliments and share successes and heartwarming stories. Every crisis has them!

Participate in Virtual Sources of Support

Several COVID-19-related resources have emerged to help healthcare workers and others care for themselves or connect with others. These are just a few:

PeerRXMD^® is a free, peer-to-peer (buddy system) program for physicians and healthcare workers that offers support, connection, encouragement, and skill-building resource.
Death over Dinner’s Healthcare Edition enables healthcare professionals to share their feelings and experiences surrounding end-of-life care.
US Department of Health and Human Services offers a Disaster Distress Helpline to help anyone dealing with distress related to natural or human disasters.
Reiki practitioner and author Sundar Kadayam offers two, free, 15-minute weekday “Peace Practice” sessions (7 am and 10 am Eastern) via Zoom to help attendees calm their minds, meditate, and embrace peace.

Please remember to honor yourself! Despite obstacles and frustrations, you are fulfilling a noble calling—taking care of those most in need.

Study: Home Hospice Helps Dementia Patients, Reduces Caregiver Burden

Mon, 27 Apr 2020 14:30:00 -0400

In a study of older patients with advanced dementia living at home in Israel, researchers found that hospice care was associated with a significant improvement in caregiver burden, perceived symptom management, and satisfaction with care among participants’ families.

The authors believe research such as this may help improve awareness that dementia is a terminal illness, and that older people with advanced dementia could benefit from hospice and palliative care.

Older patients with advanced dementia were eligible for the study if they were considered stage 7 or higher on the Global Deterioration Scale, referred to hospice, and had a full-time caregiver.

Participating patients’ existing home care was supplemented by hospice care. For a maximum of six months per patient, a specially trained physician, nurse, social worker and spiritual care provider met with families and were available 24/7.

Families provided assessments before and after receiving hospice care.

Among the 20 patients participating in the study:

Average age was 83.5.
70% were women.
Multiple chronic comorbidities were present (65% had hypertension; 40% ischemic heart failure; 30% post-stroke; 30% diabetes; 15% COPD; and 15% cancer).
Patients had been diagnosed with dementia for an average of 5.6 years.

Key Outcomes from Family Assessments

When comparing family members’ post-program responses to baseline assessments:

Caregiver burden decreased substantially (12.1 vs 1.4, with lower scores signifying less burden; P < 0.001).
Symptom management improved (post-program average score, 38.3 vs pre-program average score, 33.8; P < 0.001).
Satisfaction with care increased (35.3 vs 27.5; P < 0.001).

Key Outcomes Identified by Hospice

While five hospitalizations occurred during the study period, hospice team members identified what they determined to be 33 “prevented” hospitalizations.
An average of 2.1 medications per patient were deemed unnecessary and discontinued.

The researchers state that “all the families mentioned that the program gave them a sense of being supported and that they would recommend it to others,” adding that many said “they felt more comfortable caring for their loved one at home, that suffering had been decreased, and that they learned more about the trajectory of dementia.”

For families who chose to seek support from the social worker or spiritual care provider, those hospice team members were credited with improving family and patient well-being and reducing caregiver burden.

“Thinking of dementia as a terminal illness appropriate for hospice care was a cultural shift,” note the authors. This is not surprising, they add, since it is difficult to identify older patients with advanced dementia who likely have a six-month prognosis.

While the researchers point out some limitations to their study, they believe it lays important groundwork for further research. “[T]he insights regarding the impact and challenges of implementing a home hospice dementia model will be valuable internationally,” they conclude.

Source: “Home Hospice for Older People With Advanced Dementia: A Pilot Project,” Israel Journal of Health Policy Research; May 6, 2019; 8(1):42; DOI: 10.1186/s13584-019-0304-x. Sternberg SA, Sabar R, Bentur N, et al; Israel Ministry of Health, Division of Geriatrics; Sabar Health, Home Hospital and Hospice, both in Jerusalem; and Tel Aviv University, Tel Aviv, Israel.

Suggesting Hospice to Your Patients with Advanced Illness

Thu, 02 Apr 2020 18:18:00 -0400

Studies have shown that the vast majority of patients want to know the truth about their condition.¹ Without it, they feel abandoned and alone. Yet in today’s time-constrained environment, health care professionals (HCPs) are challenged to set aside the time to have the conversation with patients and families early and to update it regularly.²

Talking about options near the end of life while the patient still enjoys quality of life is a priceless gift from the HCP to the patient and the family. Armed with choices and an understanding of what hospice offers, an informed patient feels in control.

And much like history-taking or conducting a physical examination, broaching end-of-life discussions with patients is a skill that can be learned. Performed skillfully, these conversations strengthen doctor-patient relationships and increase the likelihood that patients will choose appropriate treatment options, such as hospice.

Barriers to Talking About Death

Concern for how the patient will react: Despite their preference to hear the truth, a patient’s initial reaction may be an emotional or physical outburst based on the prospect of limited choices, loss of control, eroding lifestyle, changing self-image and loss of life.² While an outburst may make the HCP feel uncomfortable, proper preparation and consideration of the patient’s point of view can help defuse these reactions.
Concern about the HCP’s own reaction: The HCP may worry about proper responses to a patient’s anger, panic or sadness.
Concern that the HCP can’t “do enough”: HCPs can actually strengthen the doctor-patient relationship by compassionately and honestly acknowledging their feelings about a patient’s decline despite all efforts. Talking about end-of-life options is the next logical step in the patient’s care.
Anxiety about leading such discussions: This barrier is the easiest to overcome. Take the time to learn how to have end-of-life conversations thoughtfully and compassionately. This skill not only helps patients make informed decisions, it also helps ease an HCP’s discomfort.

SPIKES has six practical components:

EOL experts recommend taking these steps now to make sure your wishes are known and carried out if you are diagnosed with a terminal disease or are approaching death and cannot speak for yourself:

S=Setting - Choose a private setting where you can sit face-to-face with the patient and a family member or confidant. If the patient does not speak English, rely on a professional interpreter rather than a family member.
P=Perception - Ask the patient how much they know, perceive or suspect before you begin the conversation.
I=Invitation - Subtly invite the patient to provide clues about willingness to receive more information. Ask if they would like to talk about test outcomes, treatments, etc. If the patient does not respond favorably, suggest that you talk again later that day or the next. Then follow through.
K=Knowledge - Share information directly and simply. After you've opened the conversation, stop talking. Listen to the patient's responses and emotions.
E=Empathy - Identify with the patient's emotional reaction in a kind way that suggests you understand and appreciate their response and are concerned about their future.
S=Summation - Summarize the news and recommend hospice care.

“SPIKE” Your Communication Skills and Confidence

Increase your ability to conduct effective conversations about ending curative treatments and embracing hospice by following the SPIKES system.¹

This will help you assess:

How much a patient understands about their disease
How ready the patient is to discuss the end of life
How to adjust to a patient’s response
The value of silence and observation
How to interpret a patient’s reaction, whether appropriate or inappropriate
How to share information with empathy
The role of hospice care in preserving hope, comfort and dignity

The Role of Hospice

Hospice plays a key role in satisfaction at the end of life. Optimal hospice care is provided for months, rather than weeks or days. When the side effects and intensity of treatment begin to outweigh any expected benefits, hospice services can help control pain, manage symptoms, facilitate comfort, and address the spiritual needs of the patient and family.

Given the gift of time, hospice patients can visit with loved ones, get outdoors, experience family milestones and put their affairs in order.

Even before hospice is considered, a VITAS physician is available for a consultation. We have the time to listen to the concerns of the patient and family, describe the progression of the advanced disease, explain care options and outline a realistic plan of care. You are informed of the outcome, and VITAS maintains communication with patient and family.

¹Buckman, Robert, and Yvonne Kason. How to Break Bad News: A Guide for Health Care Professionals. Baltimore: The Johns Hopkins University Press, 1992. Print.

²Kinzbrunner, Barry M., et. al. End-of-Life-Care: A Practical Guide. New York: McGraw Hill Companies, Inc., 2011. Print.

Originally published June 2018 and updated April 2020

Hospice Improves Quality of Life Through Comprehensive Services

Mon, 27 Apr 2020 14:30:00 -0400

In a review of relevant research in the field of end-of-life (EOL) care for cancer patients, the authors of an article published in the Journal of Clinical Oncology outline a number of key points highlighting the way hospice works to help patients with advanced cancer and their caregivers. In addition, the authors discuss ways in which EOL care can improve.

Priorities at the EOL for Cancer Patients

The authors note that several studies have aimed to explore advanced cancer patients’ and caregivers’ top priorities for the EOL. Among the most commonly expressed wishes are:

Pain and symptom control
Feeling well enough to spend time with loved ones
Dealing with unfinished business and legacy

In response, “hospice care services have grown rapidly to support families and communities to care for people at home (including in skilled nursing facilities) through excellence in physical symptom control, psychological support, spiritual care, and support for caregivers,” the authors write.

Relieving Symptom Burden

“Hospice care improves symptom control in problems prevalent at the [EOL],” the review authors explain. Symptom relief for advanced cancer patients nearing the EOL often involves addressing one or more common symptoms, including:

Breathlessness
Fatigue
Pain
Delirium

“Good analgesia is often the priority for patients and their families above any other symptom,” the authors write, adding that evidence suggests hospice provides patients with superior pain management. They note that delirium, including cognitive changes, hallucinations, and disturbances in sleep/wake cycles, can be treated with excellent nursing care, by treating any reversible causes, helping orient the patient, and providing proper hydration and nutrition.

Ideal Integration of EOL Care

The review authors urge clinicians to discuss prognosis with rapidly declining advanced cancer patients and refer to hospice care. Ideal end-of-life care for cancer patients, they point out, includes:

Competency in core EOL care skills for every health professional. This basic competency should include “recognizing the [EOL], understanding the principles of symptom control and interdisciplinary care, practicing patient-centered communication and shared decision making, having clinical skills in thorough bedside assessment, and fostering empathy and compassion.”
Specialist hospice care. The authors validate the need for “a specialist hospice/palliative care workforce” to address more complex needs. Hospice use in the last months of life has been shown to be associated with fewer hospital visits and better symptom control for advanced cancer patients. Furthermore, hospice care can be provided at home, in another location considered “home” by the patient, or at a hospice inpatient facility.
A team-based approach to care. Patients are likely to open up about more issues when they receive care from a hospice interdisciplinary team, the authors explain. “[G]iven the breadth of patient-defined needs at the [EOL], several health professionals working collaboratively will be essential to achieve the best possible patient outcomes.”
Interface between hospice and other care. In many countries, most advanced cancer patients are hospitalized or switch between locations of care near the EOL; therefore, communication between care providers is crucial. “Ensuring that both clinical teams are aware of each other’s conversations with the patient and family is a fundamental challenge that persists even in an era with improving electronic records.”

Supporting Caregivers

“The way that caregivers are supported in their new roles is a fundamental of hospice care,” the authors note. Though sparse, evidence suggest caregivers benefit most from:

Informational needs being better met
Lower rates of depression
Better ability to move forward with life after the patient’s death

“Hospice provides patients with the potential for a better quality of life, improved symptom control, and more time away from inpatient care,” the authors conclude, adding that since the majority of care for patients with advanced cancer falls to caregivers, “any additional support for them while fulfilling their role likely is to be of substantial benefit.”

Source: Currow, D.C., et al. (2020, March 20). Role of hospice care at the end of life for people with cancer. Journal of Clinical Oncology, 38(9), 937-943. DOI: 10.1200/JCO.18.02235

COVID-19: VITAS Is Educated, Committed and Ready

Tue, 02 Jun 2020 14:41:00 -0400

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

At VITAS, we put our patients, partners, employees and communities first. Given the uncertainty and concern around COVID-19, we are committed to supporting you and your staff 24/7/365.

We have taken key steps to ensure we continue providing care to our current patients as well as provide access to your hospice-eligible patients.

VITAS is educated in CDC COVID-19 guidelines and infection control:

Adherence to facility procedures, including screening protocols, direct patient-care guidelines and training on the care of COVID-19 patients and families
Mandatory staff education for VITAS care teams on infection control and up-to-date employee operating procedures consistent with COVID-19 guidelines from the Centers for Disease Control and Prevention (CDC)
Daily COVID-19 task force calls, plus regular internal employee communications on CDC, Centers for Medicare Services (CMS) and local/state health department updates

We are committed to you as a partner in care:

Commitment to uphold all components of contractual relationships and Medicare Hospice Conditions of Participation¹, as well as adhere strictly to updated CMS recommendations to facilities² and CDC guidelines
Transition your vulnerable, COVID-susceptible, hospice-eligible patients to the home or preferred care setting, relieving burdens on your staff and emergency department, and freeing your acute-care/ICU beds

We are ready to provide care, COVID-19 information and expertise:

24/7/365, VITAS supports current and new patients who can benefit from hospice services so you and your staff can focus on patients seeking curative care
Staff are trained and prepared to provide care should you refer a COVID-19-positive patient who is hospice-eligible^*
Our experts are sharing answers to frequently asked questions about hospice and coronavirus

Thank you for trusting VITAS with the care of your patients. Our mission and core values stem from decades of supporting our partners to care for hospice-eligible patients, regardless of diagnosis, complexity, acuity or social circumstance, whether facing hurricanes, fires, floods or other community tragedies.

¹Our Professional Management responsibility is defined in the Conditions of Participation (CoPs) at §418.112(b), and the Conditions of Participation require us to assess patients as often as needed and at a minimum every 15 days §418.56(d).

²Facilities should review and revise how they interact with other practitioners (e.g., hospice workers), and take necessary actions to prevent any potential transmission. Facilities can allow entry of these visitors as long as they are following the appropriate CDC guidelines Transmission-Based Precautions. For example, hospice workers can enter a facility when using PPE properly. https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf

*COVID-19-positive hospice-eligible patients will be assessed based on hospice program supply of necessary PPE (N-95 mask, goggle or face shield, and gown) to ensure the safety of our staff, patients and families.

When to Refer a Patient to Hospice

Fri, 10 Jan 2020 16:09:00 -0500

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

Health care specialists are sometimes uncertain whether their patient may be eligible for hospice services. VITAS offers several solutions to help clinicians better recognize when a patient has transitioned to this phase of life.

In general, hospice should be considered with any of the following:

When symptoms arise secondary to the diagnosis
When a patient’s disease continues to progress or when the a patient stops responding to disease-modifying treatments

Additional insights into hospice eligibility can be found on our hospice guidelines, which include general and disease-specific guidance.

In general, look for these signs over the last 4-6 months:

The illness, if it progresses as expected, has a prognosis of six months or less. (Ask yourself: “Would I be surprised to learn, six months from now, that this patient has died?” If your answer is no, request a hospice evaluation for this patient.)
Patient has a PPS rating of < 50%-60%
Patient is dependent in any 3 out of 6 ADLs
Patient has lost more than 10% body weight, or another alteration in nutritional status
Patient has had 3 or more hospital/ED visits
Decrease in physical activity
Decrease in cognitive ability

An interactive Palliative Performance Scale, which represents a strong predictor of hospice eligibility, can be found on our award-winning app; download it from the Apple App Store and Google Play.

Lastly, health care professionals can enhance their understanding of hospice including eligibility through our webinars and in-person trainings.

Empowering Underserved Populations to Embrace Hospice Care

Tue, 04 Oct 2022 04:00:00 -0400

Top 5 VITAS.com Pages for Healthcare Professionals in 2019

Wed, 29 Jan 2020 14:34:00 -0500

These VITAS.com pages for healthcare professionals received the most views in 2019:

1. Hospice Is About Choices

Everyone needs to have some control, to be given choices and asked what they prefer. When seriously ill patients transition to hospice, VITAS gives back control.

Read this article

2. VITAS Solves the Challenges of High-Risk End-of-Life Patients

When your high-risk end-of-life patient has complex needs and challenging symptoms, VITAS can help. We offer hospice and palliative care solutions and protocols that many other hospice providers do not.

Read this article

3. How Soon Do You Need Us? VITAS Is Always Available

We have clinicians on duty day and night to answer the questions of our referral sources, set up a hospice evaluation or arrange an admission. If you need a VITAS admissions nurse to see your patient in the ED at 4 a.m. we make that possible.

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4. Your Patient Can Be Home With Hospice Care

When traditional treatments or cures are no longer effective or desirable, VITAS provides hospice care for your patients at home, wherever they call home.

Read this article

5. Hospice and Palliative Care Eligibility Guidelines

Does your patient need hospice? Use our guidelines to determine if your patient needs palliative care or hospice services.

Read this article

Hospitalizations and Procedures Remain Common Among Advanced HF Patients, but Hospice and Palliative Care Can Help

Thu, 23 Jan 2020 14:51:00 -0500

"Healthcare utilization peaks at the end of life (EOL) in patients with heart failure (HF)," state the authors of a study published in Circulation: Heart Failure, noting that this trend continues in spite of research showing that aggressive care and hospital deaths often conflict with patients' and caregivers' EOL goals.

Although the study authors are optimistic—noting that both hospice and palliative care (PC) use increased among patients in their cohort through the years of the study—they advocate for increased awareness of risk factors affecting HF patient hospitalizations near death, and for increased hospice and PC referrals for HF patients.

“These data…highlight the need for EOL care pathways that encompass patients with a high comorbidity burden. Care directed only at a patient’s HF may not decrease (healthcare) utilization.”Shannon M. Dunlay, MD, MS, Mayo Clinic

HF incidence in U.S. patients is expected to continue to rise, the authors state, and they describe the resulting EOL healthcare as a "tremendous burden... on patients, caregivers and the healthcare system." Research into HF care trends and risk factors for hospitalization and other procedures near the EOL is necessary for reducing this burden and improving EOL care of HF patients, they point out.

Researchers conducted a longitudinal cohort study of adults with heart failure living in Southeastern Minnesota. The cohort included patients enrolled between 2003 and 2011 who died during the study period, which lasted through the end of 2012. Various health and demographic data were collected, including ejection fraction (EF), Charlson Comorbidity Index, marital status, and use of skilled nursing facility (SNF), hospice and PC.

Overall Findings

Among the 698 HF patients included in the study (47.3% men; mean age at death, 82 years):

81.5% were hospitalized at least once during the last year of life, with a median of two hospitalizations per person (range, 0-12); 28.4% died in the hospital.
There was a median of 14 outpatient visits per person (range, 0-119) at the EOL.
50.7% were cared for in a SNF at the EOL.
35.4% received hospice care.
26.5% received a PC consultation.
The most common causes of hospitalization were HF (22.1% of hospitalizations), pneumonia (5.2%), sepsis (4.3%) and arrhythmia (3.8%).

Risk Factors and Associations

Older patients were less likely to be hospitalized (for patients ≥ 90 years vs < 75 years: incidence rate ratio [IRR], 0.52; 95% confidence interval [CI], 0.41-0.65) or have outpatient visits in the final year of life.

Factors associated with higher EOL healthcare utilization included living in a SNF (IRR for hospitalizations, 1.35; 95% CI, 1.16-1.58; IRR for outpatient procedures, 1.48; 95% CI, 1.29-1.70) and being married or living with a partner (hospitalization IRR, 1.20; 95% CI, 1.02-1.42; outpatient IRR, 1.22; 95% CI, 1.05-1.41).

Number of comorbidities was associated with number of hospitalizations (for Charlson Comorbidity Index > 6 vs 0-2: hospitalization IRR, 1.71; 95% CI, 1.36-2.14) but not outpatient visits.

Hospice and PC Trends Over Time

During the study period, the rate of hospice use increased (2003-2006: 28.6%; 2007-2009: 34.2%; 2010-2012: 42.2%). Likewise, the number of patients receiving PC consultations increased from 10.8% from 2003-2006 to 43.6% from 2010-2012.

Resource: Hospice Admission Guidelines for Heart Disease

In addition, there was "a dramatic decline in healthcare utilization at the EOL over time, concordant with increases in palliative care consultations and hospice enrollment," the authors write. From the earliest to latest study years, hospital deaths decreased significantly (2003-2006: 32.8%; 2007-2009: 30.6%; 2010-2012: 22.4%), hospitalizations decreased by 46%, and outpatient visits decreased by 32%.

The researchers note that the dramatic increase seen in PC consultations from 2003-2012 "may reflect increased recognition by clinicians of the importance of palliative care in patients with HF approaching the EOL."

Although the authors acknowledge positive changes have occurred in HF EOL care, they stress that their findings underscore that EOL healthcare use in certain subgroups, especially those with multimorbidity, remains high. "[C]are pathways that are not HF specific, but rather encompass the growing population of patients with multimorbidity, need to be developed," they write.

Source: Dunlay, S. M., Redfield, M. M., Jiang, R., Weston, S. A., & Roger, V. L. (2015). Care in the last year of life for community patients with heart failure. Division of Cardiovascular Diseases, Dept. of Medicine, Mayo Clinic. Circulation: Heart Failure, 8(3), 489-496.

Comparing Hospice and Palliative Care

Fri, 17 Jan 2020 16:00:00 -0500

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

When your seriously-ill patient needs support, what are your options?

Clinicians understand that palliative care and hospice introduce comfort care when a patient with complex needs requires additional resources and support. Where once a physician said, “I’m sorry. There is nothing more we can do,” palliative care and hospice care provide options.

They can do so much: provide home visits, manage symptoms and meds, extend psychosocial support. Most importantly, they help introduce conversations about goals of care, values and end-of-life wishes. Palliative care and hospice open up new doors for patients and their families.

Get to know their differences so you can assure that your most complex cases get the care they need.

Palliative care indicators:

A prognosis of more than six months
A reduced response to disease-directed treatments

Palliative care services: Monthly or twice-monthly visits to home or a medical facility, as indicated, for symptom management, medication reconciliation and advance care planning

After hours: Some support may be available

Team: Physician and APRN, or equivalent

Coverage: Medicare Part B, Medicaid and some commercial insurance plans. Some treatments and drugs may not be covered. Subject to co-pay.

Grief and spiritual support: May be available

Hospice care indicators:

A prognosis of less than six months
No longer effective response to disease-directed treatments

Hospice care services at VITAS: 5-7 home visits per week, wherever the patient calls home, to meet the patient’s changing needs; from basic care to complex modalities

Four levels of care: Routine home care, intensive care at home, inpatient care, and respite care (when the caretaker needs a break)

After hours: 24/7/365 clinical support when medically necessary

Team: Physician, RN, aide, social worker, chaplain, volunteer, specialist therapists, as needed

Deliveries: Home medical equipment, medications and supplies to keep the patient comfortable

Coverage: Medicare, Medicaid, commercial insurance, self-pay. Generally no co-pay with 100% insurance coverage

Grief and spiritual support: Available to loved ones for 13 months following the death

Palliative Care and Hospice: A Partnership

Palliative care and hospice aren’t an either/or choice. They work together to transition your patients from curative care to comfort care.

They open communication with the curative team, pass that information along to the palliative team and inform the hospice team of goals, wishes, values and preferences. They establish goals of care and advance directives, at the same time opening the lines of communication within the patient’s family.

Together, palliative care and hospice ensure the right medical care at the right time in the right location of care.

When your patient is no longer responding to curative care, VITAS is available 24/7/365. Check our eligibility guidelines and refer today.

The Realities and Vision of Value-Based Hospice Care

Mon, 30 Dec 2019 21:09:00 -0500

As efforts to improve and overhaul the US healthcare system focus on a concept called “value-based care,” what can other medical providers learn from the hospice profession—particularly with its 40-year focus on care that meets patients’ needs?

And how are hospice providers themselves approaching value-based care?

Value-based care is a model that emphasizes preventive health for patients and rewards for physicians who coordinate care, provide appropriate care based on each patient’s situation and improve actual health outcomes.

Two VITAS executives—Chief Medical Officer and Senior Vice President Dr. Joseph Shega, and Senior Vice President of Strategy and Innovation Brandon Stock—recently participated in a robust American Hospital Association panel discussion about value-based care.

Participants tackled the cultural, operational and financial challenges facing hospitals and health systems as they help patients near the end of life choose and transition to end-of-life care settings.

Following are what our experts said on leading topics:

How Hospitals and Healthcare Providers Redefine the Value of the Care They Provide

Shega says that hospitals need to be committed to serving patients from birth to death.

“Setting that standard as the philosophy of your hospital or health system is a powerful message to communicate to patients and families as well as healthcare professionals,” he says. “‘Life is a journey. We’re never going to abandon you on that journey, and we’ll help you through the whole process.’ I think that’s a powerful way that health system leaders can leverage population health and support their communities. And they need to develop necessary partnerships with hospice providers to ensure the right care to patients at the end of their lives.”

When Costly, End-of-Life Care Collides with Patients’ Preferences for Comfort

“To be covered under Medicare hospice benefits, patients have to sign a statement that they choose comfort care over care aimed at curing their illnesses,” Shega says, describing the requirement as a “big barrier.”

“Patients receiving specialized treatment may worry about getting the support they need when curative measures cease,” he says. “Because of this, some patients hesitate to enroll in hospice. Even a lot of clinicians think that hospices will stop all supportive medications that patients are on... This isn't the case. Hospices are paid a daily rate per patients by Medicare. We only get a predetermined amount of money, and then we’ve got to make it work financially. For some hospices, that means turning down high-acuity patients who require specialized treatments. VITAS' for-profit status provides resources that allow us to take on any eligible patient, regardless of the severity of their illness or the treatments they require.

“(VITAS) recognizes that supportive treatments can improve the quality of life…. Comfort care can include supportive treatments that aim to reduce disease symptoms or address short-term infections. These might include antibiotics, IV fluids, total parenteral nutrition and ACE inhibitors or inotropes (a heart pump medication) for heart failure. From a cancer perspective, it might be hormonal therapy, thermotherapy or radiation intended solely for symptom relief. These treatments can improve quality of life in a patient’s final months. Restorative treatments, such as physical and occupational therapy, also can be seen as supportive when they are intended to improve quality of life.”

The Need for Seamless Healthcare/Hospital – Hospice Partnerships

Stock says VITAS is evaluating many of the new value-based care models that the Center for Medicare and Medicaid Innovation is testing to understand how hospice and palliative care can fit into these innovative approaches.

VITAS is looking at questions such as:

What do these models look like from an operational and business perspective?
How can hospice and palliative care align with hospitals, primary care and other providers?
What changes would we have to make to be successful under these models?

“We’re hoping to inform partnerships between hospice providers and hospitals by identifying performance metrics that are important to our referral sources and community partners,” Stock says. “For example, hospice helps decrease hospital re-admissions and overall Medicare spend per beneficiary, while improving the patient and family experience.

“In addition, we are developing an enterprise data warehouse which will be a single source of truth about our utilization patterns and other statistics. This is probably one of the largest, clinical data sets that exists for patients at the end of life, and we will be able to use that information to glean important insights.”

Shega believes that’s where a partnership with a hospice or palliative care provider can make a difference.

“Hospitals can leverage their partners as a resource to identify when patients would benefit from hospice and for initiating discussions with patients and families about those services,” Shega says. “The hospice partner also can help clinicians and other staff to recognize when a hospice referral would be beneficial for patients. This might help to improve care team well-being. Studies show that nurses and doctors feel a lot of moral distress when they think that patients are receiving care that they don’t think is right, such as intensive curative treatments that don’t improve (patients’) outcomes.”

How to Approach End-of-Life Care for Patients with Advanced Lung Disease

Wed, 11 Oct 2023 04:00:00 -0400

By Henri Nammour, MD, Regional Medical Director, VITAS Healthcare

Those of us who specialize in hospice and palliative medicine know the patients whose data is highlighted in two studies on advanced lung disease at end of life.

They are patients with advanced lung disease who are aware of their own declining health and new or worsening symptoms. They are patients who are not improving on current treatments and, if asked, say they would prefer to be at home for comfort-focused hospice care.

Nearly 70% of respondents to a 2017 Kaiser Family Foundation survey indicated they would prefer to die at home, if given a choice.

Yet more than 56% of patients with advanced lung disease or chronic obstructive pulmonary disease (COPD) are still dying in hospitals, nursing homes or long-term care facilities, sometimes after undergoing unwanted interventions such as intubation, CPR, and mechanical ventilation.

“Specialist palliative care in COPD and palliative care programs can provide better outcomes for patients at lower cost to the health system.” Henri Nammour, MD

Moreover, they are not being referred to hospice care in a timely manner because their physicians or specialists are not having honest conversations with them about their goals for end-of-life care. These healthcare professionals may fail to recognize the signs of decline that make seriously ill patients eligible for the hospice care that they prefer.

In a 2016 study of more than 181,000 hospitalized COPD patients, researchers found only 1.7% had received a palliative care consultation. These COPD patients were older (75+ years), experienced longer hospitalizations (4.9 vs. 3.5 days) and were far more likely to die in the hospital (32% vs. 1.5%) compared with COPD patients who are not referred to palliative care. These findings reinforce that patients should be referred to palliative care services sooner in their disease trajectory.

Indeed, specialist palliative care in COPD and palliative care programs can provide better outcomes for patients at lower cost to the health system. Timely use of palliative care for COPD patients is associated with:

fewer hospital deaths
lower costs
reduced use of high-intensity care at the end of life
a greater number of patients with advanced COPD dying at home, a preference of most of the population
increased home deaths
reduced length-of-stay during terminal hospitalizations
increased mastery of breathlessness

Although advanced lung disease is highly variable and its trajectory can be unpredictable from patient to patient, primary care physicians and specialists should understand that decline from COPD is usually apparent in the final 6-12 months of life, marked by:

increasing symptom burden, despite maximal or close-to-maximal therapies
presence of comorbid conditions or diagnoses
ongoing functional decline, marked by decreased ambulation, inability to climb stairs or daily confinement to just a few rooms, a bed or a chair
more frequent hospitalizations or use of healthcare services and increased difficulty making it to doctor or clinic appointments
increased caregiver burden, marked by family members who help more and more with activities of daily living, medications, household chores

Physicians should ask key questions when determining when to refer a COPD patient to hospice:

What percentage of a patient’s waking hours are spent sitting/lying down/resting? An answer of 50% or more is a sign of functional decline and likely eligibility for hospice referral.
Does the patient exhibit symptoms, including cough, wheezing or shortness of breath, with minimal exertion or at rest? If yes, hospice care should be considered.
Does the patient require assistance with three or more basic activities of daily living (bathing, dressing, ambulation, transfer, continence or feeding)? If yes, hospice care should be considered.

Physicians should also embrace the value of goals-of-care conversations and advance care planning with their seriously ill patients, not only to honor their patients’ wishes for medical care but also to support industry efforts to provide high-quality, cost-effective care.

A sign of progress for all patients who need end-of-life care—including those with COPD—comes from the healthcare industry’s efforts to expand palliative care and incorporate ACP into newly evolving payment models, putting hospice care on equal footing with other medical specialties and activities. Doing so will provide two benefits:

It will give patients with advanced lung disease the comfort-focused and hospice solutions they deserve in the place they prefer to be: home.
It will give physicians much-needed incentives to embrace the importance of goals-of-care conversations and follow through on them.

This article was originally published in November 2019 and updated in October 2023.

End of Life Conversations: Fewer Than Half of Physicians Feel Prepared

Thu, 14 Nov 2019 14:48:00 -0500

In a survey of physicians caring for older patients, 99% expressed the opinion that advance care planning (ACP) conversations with patients are important. Despite this, most physicians reported feeling uncomfortable about such conversations and believed that certain barriers often hindered them from initiating ACP discussions.

Researchers conducted a phone survey involving 736 actively practicing U.S. physicians (male, 81%; white race, 75%; age ≥ 50, 66%) regularly seeing patients age 65 and older, including 470 internists and primary care clinicians, 85 oncologists, 87 pulmonologists, and 94 cardiologists.

The survey questions elicited ACP opinions, experiences and perceived barriers to ACP conversations.

Researchers’ findings were published in the Journal of the American Geriatrics Society.

Key Facts: Physician Experiences

53% of respondents reported they were regularly seeing patients age ≥ 65 years who they "would not be surprised if they died within the next year."
Only 29% of respondents reported having specific end-of-life (EOL) care conversation training.
Only 14% of physicians caring for fee-for-service patients reported having billed Medicare for ACP conversations during the first year of the new benefit.

Although most reported having ACP and EOL conversations with patients, only 21% said they were doing so "frequently." Physicians with specific training and/or an assessment system in place were more likely to be having ACP conversations.

Physician Opinions and Priorities

Nearly all respondents (99%) reported feeling ACP conversations with patients are important; 51% considered them extremely important.

Physicians with EOL conversation training and/ or a formal assessment system were more likely to believe ACP conversations are extremely important.The difference in opinion was most pronounced among those with an assessment system; 61% of these physicians, compared to 47% of those without, described ACP conversations as extremely important (P < 0.05).

Respondents rated various motivating factors for having ACP discussions. The strongest motivators were honoring patients' values and wishes, which 92% cited as very or extremely important, and reducing unnecessary or unwanted hospitalizations.

Barriers to EOL Care Discussions

Interviewees were asked whether certain barriers had "ever gotten in the way of talking to [patients] about their [EOL] wishes." The most commonly cited barriers include:

Lack of time (66% of respondents)
Disagreements between patient and family (65%)
Feeling unsure of timing (60%)
Concerns the conversation might be uncomfortable (51%)
Not wanting to lose hope (46%)
Being unsure what's culturally appropriate (44%)

"Given the gap between what people want at the end of life and the care they receive, we need to build on available training tools and embed them systematically into practice," the authors state. They advocate for "broadly available" ACP conversation training and use of a formal assessment system.

SPIKES: A Method for Approaching EOL Conversations

EOL experts recommend the SPIKES method for discussing hospice care with a patient:

S=Setting: Choose a private setting where you can sit face-to-face with the patient and a family member or confidant. If the patient does not speak English, rely on a professional interpreter rather than a family member.
P=Perception: Ask the patient how much they know, perceive or suspect before you begin the conversation.
I=Invitation: Subtly invite the patient to provide clues about willingness to receive more information. Ask if they would like to talk about test outcomes, treatments, etc. If the patient does not respond favorably, suggest that you talk again later that day or the next. Then follow through.
K=Knowledge: Share information directly and simple. After you've opened the conversation, stop talking. Listen to the patient's responses and emotions.
E=Empathy: Identify with the patient's emotional reaction in a kind way that suggests you understand and appreciate their response and are concerned about their future.
S=Summation: Summarize the news and recommend hospice care.

Learn More: Having EOL Conversations With Your Patient

Source: Fulmer T, et al. (2018). Physicians' Views on Advance Care Planning and End-of- Life Care Conversations. Journal of the American Geriatrics Society. DOI: 10.1111/ jgs.15374

COPD Patients: Experts Call for Earlier Referral to Palliative Care and Hospice

Thu, 14 Nov 2019 14:48:00 -0500

Early palliative care (PC) in patients with severe chronic obstructive pulmonary disease (COPD) may “improve the end-of-life experience and increase hospice use,” state the authors of a letter published in CHEST, in which they report on a retrospective study they conducted on trends and disparities in hospice use among patients dying of COPD.

Noting that “PC involvement should start early in the course of illness to prevent costs and burden associated with end-of-life hospitalizations,” researchers from Cleveland Clinic analyzed the places of death among patients in the U.S. aged ≥ 50 who died of COPD from 2006-2015 (n = 1,242,350).

The research team’s analysis was based on data from the U.S. Mortality Files compiled by the Centers for Disease Control, National Vital Statistics System.

Places of Death for COPD Patients

33.6% in a hospital
28.6% at home
22.5% in a nursing home/long-term care facility
5.9% in hospice care (at any location)
4.5% other/unknown
0.4% dead on arrival at hospital

While the overall percentage of hospice deaths among COPD patients increased from 2.2% to 9.3% from 2006-2015 (P < 0.001), the authors emphasize that “only a minority of patients with COPD die at home or in hospice.”

Hospice Use Findings

Patients more likely to die of COPD in hospice included:

Whites (6.1% vs 4.2% of African Americans; P < 0.001).
Older patients (odds ratio, 1.04; 95% confidence interval, 1.03-1.04 per 5 years; P < .001).
Women (6.1% vs 5.7% of men; P < 0.001).

Significant regional variations in hospice deaths were also found (Northeast, 4.1%; Midwest, 4.7%; South, 8.1%; West, 4.7%; P < 0.001).

The authors note that their findings mirror a number of important trends reported by Rush et al in their COPD study published earlier in CHEST.

In the Rush study, investigators conducted a retrospective analysis of adult COPD patients (n = 181,689). While the percentage of patients receiving a PC referral increased from 0.45% to 2.56% between 2006 and 2012 (P < 0.01), Rush states that “referral to PC remains uncommon,” and they advocate for earlier referral for these patients. In addition, they found significant racial disparities in PC referral, “with white patients referred more often than minorities.” (P < 0.01).

In commenting on the Cleveland Clinic study’s findings, Rush concludes, “Our hope is that this combined work will increase awareness of the benefits that PC can have on this patient population. Future studies need to be undertaken to demonstrate the benefit of PC referral in reducing hospitalizations and improving patient quality of life.”

Sources: Yaqoob ZJ, et al. (2017). Trends and Disparities in Hospice Use Among Patients Dying of COPD in the United States. CHEST (Letter to the editor), 151(5):1183-1184. Rush B, et al. (2017). Use of Palliative Care in Patients with End-Stage COPD and Receiving Home Oxygen: National Trends and Barriers to Care in the United States. CHEST, 151(1):41-46.

Inpatient Hospice Guidelines for Our Patients

Tue, 24 Jan 2023 05:00:00 -0500

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

When you refer your patient to hospice care with VITAS, we help to determine the best care setting. Most of the time, hospice care is provided to the patient at home or the patient’s preferred setting, such as a nursing home or assisted living community. Sometimes, patients require inpatient care.

When the VITAS hospice interdisciplinary team determines a hospice patient’s symptoms and pain can no longer be managed and controlled at home, the team may move the patient to a 24-hour inpatient hospice unit or care facility.

General inpatient (GIP) care is one of four levels of care that Medicare requires hospices to offer in order to be certified to provide services. At VITAS inpatient hospice facilities, care is provided in a home-like setting. Friends and family members are welcome to visit at any time in accordance with safety guidelines, and overnight stays can be arranged.

Once symptoms and pain stabilize during inpatient hospice care, the patient can return to hospice care in their preferred setting.

Which Patients Qualify for Inpatient Hospice Care?

A variety of hard-to-manage symptoms may indicate that a patient is eligible* for inpatient hospice care:

Sudden deterioration that requires intensive nursing intervention
Uncontrolled pain
Uncontrolled nausea and vomiting
Fractures with symptoms
Unmanageable respiratory distress
Symptom relief via intravenous medications that require close monitoring
Wound care that requires complex and/or frequent dressing changes that cannot be managed in the patient’s residence
Unmanageable agitation; delirium; or acute severe anxiety
Uncontrolled seizures

Consult our disease-specific guidelines help determine hospice eligibility.

*Decisions regarding eligibility for a level of care are made by the physician in conjunction with the interdisciplinary team.

When Are Patients Discharged from Inpatient Hospice Care?

Inpatient hospice care is intended to be temporary, allowing patients to return home to familiar surroundings, loved ones, and a routine level of care as soon as possible. The following guidelines indicate a patient may be ready to discharge from inpatient care:

Symptoms have stabilized
The patient has transferred to another level of care (i.e., continuous care)
Medication requiring skilled nursing care is no longer necessary

Who Pays for Inpatient Hospice Care?

Medicare Part A covers up to 100% of the cost of hospice care related to a hospice-eligible patient’s diagnosis, with no deductible or copayment. For patients with Medicare Advantage, hospice is covered by original Medicare. Patients with a private or employer-provided health plan should check with their insurance provider for details about hospice eligibility, coverage and out-of-pocket expenses. Medicaid coverage for hospice care varies by state.

When care unrelated to a patient’s advanced illness is necessary, Medicare Parts A and B may cover expenses under normal rules.

Questions About Inpatient Hospice?

When symptoms can no longer be managed at home, inpatient hospice care from VITAS offers round-the-clock inpatient care in a warm and comforting environment. If your patient or resident with advanced illness is living with complex symptoms and serious pain, schedule a consultation with VITAS and help your patient embrace quality of life near the end of life. Contact VITAS via phone, app or referral form today to determine whether hospice is right for your patient.

Originally published in October 2019.

Top 5 Things for Healthcare Professionals to Understand About Sepsis

Wed, 09 Jul 2025 04:00:00 -0400

By Joseph Shega, MD, Chief Medical Officer, VITAS Healthcare

Sepsis affects 50 million people worldwide per year, resulting in 11 million deaths¹. Thanks to ongoing research, updated statistics, and evolving protocols, clinical treatment of sepsis has evolved in recent years.

These findings are changing how we understand the progression of sepsis, allowing for more accurate assessments of which patients are likely to benefit from aggressive treatment or palliative care, and which may be better served by timely referral to comfort-focused hospice care.

5 Facts to Know About Sepsis

Sepsis is the most expensive condition in US hospitals, accounting for $62 billion annually. Readmission costs average $25,000 per patient²
Sepsis is often fatal. 41% of patients admitted to the hospital with sepsis die within 90 days³. Nearly half of those patients met hospice eligibility at the time of admission due to an underlying terminal condition such as advanced lung disease, cancer, dementia, or advanced heart failure. Evaluating contributing factors at the time of admission can help clinicians determine appropriate treatment.
Patients who survive sepsis are at an increased risk of readmission. Of those who survive, 42% are readmitted within 90 days³. Studies indicate that referral to hospice can reduce hospital readmissions by over 80% and improve quality of life⁴.
Nearly one-third of sepsis survivors (30%) suffer from post-sepsis syndrome, including new functional limitations, increased cognitive impairment, difficulty swallowing, increased depression and anxiety, and exacerbation of chronic medical conditions⁵.
Adopting a “whole person” approach to evaluating patients can be extremely beneficial in determining appropriate sepsis treatment. Tailoring sepsis protocols to individual disease trajectories can reduce sepsis-related readmissions by up to 90% if end-of-life patients are identified and referred to hospice care earlier⁴.

Treatment Protocols for At Risk Patients

With this information in mind, clinicians should consider the three-tier classification for sepsis patients, defined as “healthy,” “multimorbidity,” or “hospice-eligible,” and tailor care protocols appropriately.

Healthy patients are most likely to respond to aggressive interventions. Multimorbidity patients should be offered optimum symptom management with palliative care that supports both their disease trajectory and quality of life.

For hospice-eligible patients, clinicians should explain the prognosis and emphasize the benefits of timely hospice referral for both the patient and their family. Facilitating goals-of-care conversations can reduce family depression, anxiety, and post-traumatic stress disorder, independent of a patient’s death.

This was originally published in August 2019 and updated in July 2025.

1 World Health Organization. (2021). WHO calls for global action on sepsis: cause of 1 in 5 deaths worldwide. Retrieved from: https://www.who.int/news/item/08-09-2020-who-calls-for-global-action-on-sepsis---cause-of-1-in-5-deaths-worldwide

2 Buchman, T., et al. (2020). Sepsis Among Medicare Beneficiaries: 3. The Methods, Models, and Forecasts of Sepsis, 2012-2018. Critical Care Medicine; 48:302-318.

4 Holden, T, et al. (2015). Hospice enrollment, local hospice utilization patterns, and rehospitalization in Medicare patients. Journal of Palliative Medicine, 18(7), 601–612.

5 Thompson, K., et al. (2018). Health-related outcomes of critically ill patients with and without sepsis. Intensive Care Med, 44(8):1249-1257.

Sepsis Outcome of Death or Discharge Remain Steady

Tue, 20 Aug 2019 00:00:00 -0400

According to a recent study published in JAMA, incidence and mortality rates of sepsis in the United States appear to have remained constant in recent years based on clinical data, despite the higher incidence and lower mortality suggested by claims-based data.

"Despite its importance, reliably measuring sepsis incidence and trends is challenging," the study authors write. As sepsis awareness increases and sepsis coding practices change, they voice concerns about the reliability of claims-based trends.

“…neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009–2014.”
-Chanu Rhee, MD, MPH, Harvard Medical School

The retrospective cohort study looked at claims-based data and clinical electronic health record (EHR) data from patients 20 years or older admitted to 409 US hospitals from 2009 to 2014. Researchers identified sepsis cases from EHR data using an adapted version of the Third International Consensus Definitions for Sepsis and Septic Shock, with sepsis defined as presumed infection alongside signs of acute organ dysfunction.

Clinical vs. Claims-Based Trends from 2009-2014

Sepsis Identification. Investigators found that EHR clinical criteria were more sensitive in identifying sepsis than claims-based methodology (69.7% vs 32.3%).
Sepsis Incidence. During the study period of 2009-2014, sepsis incidence from EHR data remained stable, with a marginal increase of .6% per year, while incidence using claims data increased significantly by 10.3% per year.
In-Hospital Mortality. Using EHR data, in-hospital mortality decreased slightly by 3.3% per year, while claims data showed a significant declining mortality rate of 7%.
Combined Outcome of Death or Discharge to Hospice. When analyzing EHR data, no major change was found to the combined outcome of death or discharge to hospice, with a marginal decrease of 1.3%. By comparison, analysis using claims data found a significant decline of 4.5% per year.

‘A Major Public Health Problem’

"Reliable sepsis surveillance is essential given its high burden," the authors state. “Sepsis is a major public health problem. It is among the most expensive conditions treated in US hospitals and a leading cause of death.”

In light of the fact that claims data "can be biased by changing diagnosis and coding practices over time,” these findings suggest that EHR-based data may show more accurate sepsis trends than claims data. Hence, the authors conclude that based on clinical data, sepsis incidence and mortality seem to have remained fairly constant from 2009-2014.

Source: "Incidence and Trends of Sepsis in US Hospitals Using Clinical vs. Claims Data, 2009-2014," JAMA; October 3, 2019; DOI: 10.1001/jama.2017.13836. Rhee C, Dantes R, Epstein L, Murphy DJ, Seymour CW, et al; for the CDC Prevention Epicenter Program; Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston; Department of Medicine, Brigham and Women's Hospital, Boston; and Division of Hospital Medicine, Department of Medicine, Emory University School of Medicine, Atlanta.

Sepsis Hospital Readmissions Higher Than Non-Sepsis

Tue, 20 Aug 2019 00:00:00 -0400

Sepsis patients are at a significantly higher risk of hospital readmission and post-acute care use than non-sepsis patients, according to the results of a two-year observational cohort study published in the Annals of the American Thoracic Society. Investigators also found that hospital readmissions after sepsis are more likely to result in death or discharge to hospice.

“Given the frequency of hospice use among survivors...the question (of) whether timely access to palliative care could be optimized for targeted subgroups...is an additional direction worth pursuing.”
-Mark E. Mikkelsen, MD, MSCE, Perelman School of Medicine, University of Pennsylvania

"Sepsis is a growing public health problem," the study authors state, noting that "improving care transitions and reducing 30-day hospital readmissions have become a national priority in the United States." However, research into these topics has been sparse, they write.

University of Pennsylvania (UP) researchers set out to compare post-acute care use, rehospitalization rates and readmission outcomes of sepsis patients vs. those without sepsis between 2010 and 2012, and to identify risk factors for post-sepsis rehospitalization. The study cohort included 112,578 adult hospital admissions (73,999 unique patients) to UP Health System who were discharged and not transitioned to hospice, and therefore at risk for readmission.

Overall Findings

Sepsis was present in 4.4% of the initial eligible hospitalizations.
2.2% of the initial sepsis hospitalizations resulted in death and 1.9% resulted in transition to hospice.
Patients with sepsis were more likely to be older (P = 0.005), male (P < 0.001), single (P= 0.02), Medicare beneficiaries (P < 0.001), to have a greater number of comorbid conditions (P < 0.001), and to have a malignancy diagnosis (P < 0.001).

Key Findings

30-day readmission rate was 27.3% for sepsis and 15.6% for non-sepsis (P < 0.001).
Post-acute care usage, driven by skilled care facility placement, was higher post-sepsis than non-sepsis (35.4% vs 15.8%).
Death or transition to hospice was more likely in post-sepsis readmissions (13.3% vs 6.1% non-sepsis; P < 0.001).
Several independent risk factors were found to be associated with 30-day rehospitalization after sepsis, including: malignancy diagnosis (P < 0.001); greater number of hospitalizations within the prior year (P < 0.001); nonelective index hospitalization (P = 0.02), and having one or more procedures during hospitalization (P < 0.001).

The study authors stress that readmission, post-acute care and mortality are common after sepsis, and that awareness is vital. They point out that the readmission rates after sepsis are comparable to those of conditions identified as high risk by the Centers for Medicare & Medicaid Services, noting these findings “support the recommendation that sepsis is an additional condition that warrants attention at the national level.”

In conclusion, the authors suggest that “timely access to palliative care services could be optimized for targeted subgroups, given the frequency of hospice use” in this patient population.

Source: "Post-Acute Care Use and Hospital Readmission after Sepsis," Annals of the American Thoracic Society; June 2015; DOI: 10.1513/AnnalsATS.201411-504OC. Jones TK, Fuchs BD, Small DS, Halpern SD, Hanish A, Umscheid CA, Baillie CA, et al; Department of Medicine; Division of Pulmonary, Allergy, and Critical Care; and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia.

Sepsis Hospital Readmissions Found to Be Common and Costly

Fri, 31 May 2019 00:00:00 -0400

Experts Recommend Timely Access to Hospice

The striking proportion of sepsis patients who undergo hospital readmissions continues to be common and costly, according to the authors of a study published in CHEST^® Journal.

The researchers recommend further research and action—including timely referral to hospice and palliative care in critically ill older patients and in patients with active malignancies—in order to prevent potentially unnecessary rehospitalizations.

“Our findings serve to create awareness among clinicians, administrators and policy makers alike regarding patient populations that are vulnerable to sepsis readmission.”

Current research has shown that patients rehospitalized after sepsis tend to have more costly readmissions and longer length of stay (LOS) than patients with acute myocardial infarction (AMI), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia, several of the most common conditions among hospital readmissions.

Data from the Healthcare Cost and Utilization Project’s National Readmission Database (NRD) provided a cohort of 1,030,355 US patients 18 years of age or older who were hospitalized for sepsis during 2013 or 2014.

The annual US cost of sepsis readmissions estimated from this study is $3.5 billion.

Overall Findings

The mean age of patients hospitalized for sepsis: 66.8 ± 17.4 years; 51.7% were women
12.8% of patients died during initial hospitalization
Of surviving patients, 17.5% were readmitted within 30 days; 9.2% died during rehospitalization within 30 days
The median time to readmission: 11 days (interquartile range, 5–19 days)
The primary cause for readmission: infections (42.2%)
Hospital readmission was associated with a higher cost of hospitalization ($24,291 vs $18,611, P < .001)

Predictors and Risk Factors of 30-Day Readmission

A multivariable regression model identified several strong predictors of 30-day readmission:

Presence of a chronic health condition such as diabetes, chronic lung disease, chronic kidney disease and CHF (all P < .001)
Discharge to a short- or longterm facility vs. home (P < .001)
Higher burden of comorbidities (P < .001)
Longer LOS during initial hospitalization

“Our findings serve to create awareness among clinicians, administrators and policy makers alike regarding patient populations that are vulnerable to sepsis readmission,” the authors conclude, with an aim to “develop strategies in terms of quality of care and care transitions.”

Source: “Epidemiology and Predictors of 30-Day Readmission in Patients with Sepsis,” CHEST® Journal; March 4, 2019; DOI: 10.1016/j.chest.2018.12.008. Gadre SK, Shah M, Duggal A; Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland; and Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania.

Largely Unpreventable, Sepsis Hospital Deaths Are Prevalent

Tue, 30 Jun 2020 13:19:00 -0400

Despite the prevalent view that most sepsis-based deaths are preventable with better care, the authors of a study published in JAMA Network Open report that it is unlikely that a large proportion of these deaths can be prevented.

While the authors agree that optimal treatment of sepsis is definitely important to avoid preventable deaths, they suggest that, rather than focusing primarily on improving hospital-based sepsis treatment, the effects of sepsis may be better minimized by improving awareness about vulnerable patient populations and managing serious comorbidities that often occur alongside death by sepsis.

40% Were Hospice-Eligible But Weren't Referred

One of the study’s key findings: 40.3% of patients who died from sepsis exhibited hospice-qualifying conditions at the time of admission but were not referred to hospice for care.

“Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.” —Chanu Rhee, MD, MPH Harvard Medical School

Many deaths in the US involve sepsis (possibly more than 250,000 each year), according to the authors, and yet sepsis is often underreported among hospital discharge codes and death certificates. As a result, the prevalence, causes and best approaches to care can be difficult to study.

“Sepsis disproportionately affects patients who are elderly, have severe comorbidities, and have impaired functional status,” the authors note. “As a result, some of these patients may receive optimal, guideline-compliant care yet still die due to overwhelming sepsis or from their underlying disease.”

Researchers performed a retrospective analysis of adult patients admitted to six US hospitals between 2014 and 2015 who died or were enrolled in hospice and not readmitted. Clinicians reviewed the medical records of 568 patients who died of sepsis during the study period.

These reviewers rated the preventability of death from 1 to 6 on a Likert scale (1, definitely preventable; 2, moderately likely to be preventable; 3, potentially preventable under ideal circumstances; 4, unlikely to be preventable even though some circumstances may not have been optimal; 5, moderately likely not to be preventable; and 6, definitely not preventable due to fatal illness and/or goals of care precluding aggressive treatment). Clinicians also identified any suboptimal aspects of care.

Overall

Of 568 patients in the analysis, mean age was 70.5
395 (69.5%) died in the hospital, and 173 (30.5%) were discharged to hospice
Among sepsis-associated deaths, 121 of 300 patients (40.3%) were eligible for hospice at the time of admission to the hospital

Prevalence of Sepsis and Serious Comorbidities

Sepsis was present in 300 hospitalizations (52.8%; 95% confidence interval [CI], 48.6%–57.0%) that resulted in death. Researchers found 121 of the 300 patients who died with sepsis (40.3%; 95% CI, 34.7%–46.1%) to have “end-stage comorbidities” as defined by hospice criteria. The most common comorbidities were solid cancer (20.0%), refractory hematologic cancer (5.3%), severe dementia (5.0%), severe stroke (4.0%) and severe chronic lung disease (5.3%).

Sepsis was considered the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%– 38.9%). Of an additional 102 patients (18.0%; 95% CI, 14.9%– 21.4%) for whom sepsis was present but resolved before death, reviewers still considered sepsis to contribute to the death of 44 (43.1%; 95% CI, 33.4%–53.3%).

The most common underlying causes of death in sepsis patients were solid cancer (21.0%), chronic heart disease (15.3%), hematologic cancer (10.3%), dementia (9.7%) and chronic lung disease (9.0%), the authors write.

Preventability of Sepsis Deaths

Among patient deaths involving sepsis:

264 (88.0%; 95% CI, 83.8%–91.5%) were judged to be definitely or most likely unpreventable (4 to 6 on a Likert scale)
Only 36 (12.0%; 95% CI, 8.6%–16.2%) were judged possibly preventable (1 to 3 on a Likert scale); of these, only 11 (3.7%) were definitely or moderately likely preventable
232 (77.3%) had “no identifiable suboptimal aspects of care”
68 (22.7%) had aspects of suboptimal care. Of these, 32 (47.1%) were judged definitely, moderately or possibly preventable

“Patients who died with sepsis tended to be older adults with multiple comorbidities and recent hospitalizations, and underlying causes of death were mostly associated with severe chronic comorbidities,” the authors say.

Consistent with previous studies, these results suggest a large proportion (over 50%) of adult hospital deaths and discharges to hospice likely involve sepsis, despite the fact that a much smaller proportion (approximately 6%) of death certificates indicate the presence of sepsis.

Hospice Guidelines for Patients with Sepsis and Concomitant End-Stage Disease >

“[A]lthough the burden of sepsis-associated mortality is high, our study indicates that most of these deaths may not be preventable through better hospital-based care,” the authors write, noting that clinician reviewers found most cases of sepsis-associated death to be unpreventable due to “incurable underlying diseases” or severe illness that persisted despite appropriate treatment.

Although the study did identify some cases of suboptimal care among patients dying of sepsis, the authors stress that these cases were infrequent, occurring in less than one-quarter of cases, and that “death was still thought to be unpreventable in more than half of those patients.”

The findings suggest that only about 1 in 8 sepsis-associated deaths may be preventable, the authors state, with only 1 in 25 being judged definitely or moderately preventable. “Our findings do not diminish the importance of trying to prevent as many sepsis-associated deaths as possible,” they write, “but rather underscore that most fatalities occur in medically complex patients with severe comorbid conditions.”

Source: “Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals,” JAMA Network Open; February 15, 2019. Rhee C et al; Department of Medicine, Brigham and Women’s Hospital; and Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, both in Boston, Massachusetts.

Clinicians' Overestimation of Cancer Patient Survival Affects End-of-Life Outcomes

Thu, 24 Aug 2023 04:00:00 -0400

A cohort study that followed advanced cancer patients who engaged in a palliative care (PC) consultation between 2013 and 2016 found that patients' likely survival time was often overestimated by palliative care clinicians, and that this overestimation occurred more frequently when patients were African American or Latino. Further, the researchers determined that overestimation of prognosis corresponded with less hospice use, which suggests that this “optimistic bias” has an effect on the course of cancer patients' end-of-life (EOL) care.

A knowledge gap exists surrounding indicators of poorer prognosis in patients with advanced illness, a gap that contributes to missed opportunities for hospice services and significant delays in access for those who are referred to hospice care.

Do Clinicians Know When EOL Is Happening?

“Estimating survival time in serious illness is a challenging and important task for clinicians who care for the seriously ill,” write the study authors, who note that the majority of people report a preference for comfort care over longevity near the EOL, yet more than 80% of Medicare beneficiaries die without any hospice enrollment or are enrolled within 72 hours of death.

One hypothesis explaining this “mismatch” between many patients' EOL preferences and their actual care is that “clinicians' optimistic bias in survival estimation prevents patients and clinicians from knowing when EOL is happening,” the authors write.

In order to assess the prevalence of survival overestimation and its effect on patients, researchers analyzed data and survey responses of 230 English-speaking advanced cancer patients and their PC clinicians at two US academic medical centers. Patients were asked about their EOL preferences—whether they would prefer comfort and quality of life over survival time—to gauge opinions affecting hospice use. After six months, patients or their informants were contacted to confirm survival time, hospice enrollment, and whether aggressive treatments “with little or no value to comfort in advanced cancer” were used within 14 days of death. The treatments included cardiopulmonary resuscitation, mechanical endotracheal ventilation or feeding tube.

PC clinicians were asked to make a “best guess” about the patients' survival time following the PC consultation, “assuming that their illnesses are allowed to take their natural course.” Clinicians marked each patient's likely survival time as: < 24 hours; 24 hours to < 2 weeks; 2 weeks to < 3 months; 3 months to < 6 months or > 6 months.

Overall

Patients were a median age of 63 years (interquartile range [IR], 54 to 71 years); female gender, 50%; self-identifying as non-white, 24%; self-identifying as either African American or Latino, 20%.
53% of patients said they “strongly agree” they would prefer comfort and quality of life to survival time, as opposed to 6% who chose “strongly disagree.”
Patients lived for a median of 37 days (IR, 12 days to 97 days).

Key Findings

PC clinicians effectively determined patients' survival time relative to one another, and were accurate with respect to absolute survival time in 41% of cases, consistent with previous research.
PC clinicians were nearly six times more likely to overestimate than to underestimate survival time (85% vs 15%; P < 0.001), and 50% of patients had an overestimated survival time.
Among patients who died within six months, overestimation of survival was associated with no or late hospice use (odds ratio [OR], 0.45; 95% confidence interval [CI], 0.24 to 0.83) and more aggressive treatment at EOL (P < 0.05). Controlling for potential confounding variables did not weaken this association, and when the 15 patients who did not prefer comfort EOL care were excluded, the association was stronger (OR, 0.39; 95% CI, 0.21 to 0.76).

Higher Survival Overestimation for African American and Latino Patients

PC clinicians were significantly more likely to overestimate survival time of patients who identified as either African American or Latino (66% vs 46%), even when adjusting for potential confounding (adjusted OR, 3.89; 95% CI, 1.64 to 9.22). This association between racial and ethnic identity and prognosis overestimation persisted when patients who did not prefer comfort EOL care were excluded (adjusted OR, 4.03; 95% CI, 1.69 to 9.63).
African American and Latino patients survived as long as other patients (hazard ratio, 1.07; 95% CI, 0.76 to 1.51) and were not significantly more likely to be opposed to comfort-focused EOL care (11.1% vs 5.1%; P = 0.13).

Implications for Improving EOL Care

“To our knowledge, this study is the first to identify an empirical link between clinician survival overestimation and actual patient EOL outcomes,” the authors state. “We hypothesize that overestimation might act via direct pathways (i.e., communication of prognostic estimate or confirmation of hospice eligibility) or indirect ones (i.e., focus of clinician's diagnostic attention to treatment-related suffering) to influence hospice use,” they write.

Whereas previous research found that a source of racial/ethnic disparity in EOL care may be poor communication of estimated prognosis, the authors write that these findings “suggest that the accuracy of what clinicians believe to be true regarding survival prognosis differs by race/ethnicity.”

While they note that these outcomes do not identify a cause for the racial and ethnic disparities observed, the study authors stress that greater awareness of the common survival overestimation African American and Latino patients face seems like an important focus when it comes to reducing the effects of overestimation. They describe these racial and ethnic disparities in preference-concordant EOL care as “substantial” but “plausibly mutable.”

Related: Improving End-of-Life Care Disparities with Disease-Specific Education and Advocacy >

Overall, the authors write that the research findings “identify prognosis overestimation in advanced cancer to be an important, timely and a promising target for interventions that promote preference-concordant and equitable EOL care,” and they endorse the “systematic use” of prognostic tools to help give seriously ill patients the EOL care they prefer.

Originally published February 14, 2019 and updated August 24, 2023.

Source: “Palliative Care Clinician Overestimation of Survival in Advanced Cancer: Disparities and Association with End-of-Life Care,” Journal of Pain and Symptom Management; October 2018; DOI: 10.1016/j.jpainsymman.2018.10.510. Gramling R, Gajary-Coots E, Norton SA, et al; University of Vermont, Burlington, Vermont; and University of Rochester, Rochester, NY.

Important Palliative Care Discussions with COPD Patients: Too Little, Too Late?

Wed, 15 Aug 2018 00:00:00 -0400

Patient-physician discussions of palliative care issues are crucial to ensuring that patients with chronic obstructive pulmonary disease (COPD) understand the nature of their illness and have their care preferences honored as their condition worsens.

Yet these conversations occur infrequently, are held late in the disease course and seldom cover topics patients need and want to discuss, according to a report published in ERJ Open Research, a journal of the European Respiratory Society.

“The findings indicated that the frequency and quality of palliative care conversations is generally poor,” write the authors. “The occurrence of discussions was associated with higher health status and of a higher quality of dying and death.

“Patients were also more likely to report having received the best possible care, to acknowledge that their provider knew the treatments they wanted and to state that their doctor provided a very good explanation of their breathing problems if they engaged in conversations,” they add.

Investigators analyzed English-language studies and articles identified through a systematic review of the literature from 1996 to 2015 on palliative and end-of-life care discussions between healthcare professionals and adult patients with COPD. Papers were quality assessed, analyzed and synthesized, with only those scoring medium to high quality included, resulting in a total of 37 papers, 20 of which originated in the US.

Key Findings:

Frequency: More than half of COPD patients reported a desire to discuss palliative care topics. However, the percentage of such discussions actually occurring ranged from 0% to 54%.
Timing: Discussions of treatment preferences were most likely to occur during the advanced stage of disease or when a serious decline had been noted. All pulmonologists agreed, however, that such discussions should be initiated when the patient’s condition is stable.
Healthcare professional: Patients generally desired to have palliative care conversations with a physician they knew and who knew them as a person, rather than with a clinically competent but unfamiliar specialist.
Topics: The majority of COPD patients rated the quality of palliative care discussions as low, particularly when end-of-life care topics were not discussed. Topics desired by patients included prognosis, spiritual beliefs and what to expect as death approached.
Education: The vast majority of patients were unaware of palliative care as an option. “Overall, patient education about palliative care was ranked as one of the most important topics by patients with COPD,” write the authors. “The most important educational area for end-stage COPD patients was the progressive and irreversible nature of COPD.”

Commonly Cited Barriers to Palliative Care Communication

Patient-Identified Barriers:

Keeping the focus on staying alive
Uncertainty about which physician would be caring for them
Not knowing what type of care they would want
Limited understanding of COPD and palliative care
Avoidance of emotional distress
Denial of impending death

Physician-Identified Barriers:

Time constraints
Prognostic uncertainty
Lack of knowledge about the patient
Uncertainty about timing of and approach to conversations
Perception that palliative care is confined to the last days of life
Complexity of discharge planning for COPD patients

How to Improve Communication

Start early in the disease course.
Be prepared to discuss the implications of the diagnosis, prognosis and possible outcomes of life-sustaining treatments.
Ascertain the patient’s understanding of their condition. Include family members if the patient so wishes.
Identify and acknowledge patient preferences.
Share your medical opinion. Propose a treatment plan in alignment with the patient’s needs and wishes.
Provide support if the patient becomes upset or emotional. Negotiate any disagreements, so as to arrive at a shared decision.
Document all topics discussed and agreed upon, and work with other healthcare professionals to ensure the patient’s wishes are followed. Re-initiate conversations if the patient’s medical situation changes, or at the patient’s request.

“Healthcare professionals looking after COPD patients ... can use this review as an accurate reference for their day-to-day clinical practice,” the authors suggest. They call for further research to determine the best “new pathways and practices to improve outcomes for COPD patients by ensuring timely and appropriate integrated palliative care and advance care planning” through patient physician conversations.

Source: “Palliative and End-of-Life Care Conversations in COPD: A Systematic Literature Review,” ERJ Open Research; April 27, 2017; 3(2). Tavares N, Jarrett N, Hunt K, Wilkinson T; Portsmouth Hospitals NHS Trust, Portsmouth; NIHR CLAHRC Wessex, Southampton; and Faculty of Health Sciences, University of Southampton, all in the UK.

Hospice Referral at Discharge Linked to Lower 30-Day All-Cause Readmissions among Heart Failure Patients

Mon, 23 Jan 2017 00:00:00 -0500

Approximately 25% of patients hospitalized for decompensated heart failure (HF) are readmitted within 30 days of discharge, making HF the leading cause for 30-day all-cause readmissions in the U.S. However, those HF patients enrolled in hospice at discharge are significantly less likely to be readmitted to hospital for any reason, according to a report published in Circulation: Heart Failure.

“To the best of our knowledge, this is the first study to report a robust independent association of discharge hospice referral and lower 30-day hospital readmission in Medicare beneficiaries with HF regardless of EF (ejection fraction),” write the authors.

“Furthermore, this beneficial association of hospice referral with readmission was observed throughout the entire six months post-discharge period and was unaffected by all-cause mortality,” they add.

Investigators analyzed data from patient medical records linked to Medicare utilization files for 8,032 beneficiaries hospitalized for decompensated HF from 1998 to 2001 (mean age, 79 years; female, 58%; non-white, 18%) in one of 106 Alabama facilities. Propensity scores were used to assemble a matched cohort of 179 patients referred to hospice at discharge (“hospice-referral patients”) and 179 patients who died within six months but had not been referred to hospice (“hospice-eligible” patients).

Overall Findings

22% of all patients died within six months; 8% of these patients were discharged to hospice.
2% overall were discharged to hospice.
21% of patients were readmitted for all causes within 30 days of discharge.

Outcomes: Hospice versus No Hospice

30-day all-cause readmission occurred in 41% of the patients not referred to hospice who died within six months (“hospice-eligible patients”) and 5% of hospice-referral patients (hazard ratio [HR] associated with hospice referral, 0.12; 95% confidence interval [CI], 0.06 to 0.24).
Among patients who survived for the first 30 days, 30-day all-cause readmission occurred in 39% and 8% of hospice-eligible patients and hospice-referral patients, respectively (HR, 0.17; 95% CI, 0.08 to 0.36).
Among those patients who died in the first 30 post-discharge days, 30-day all-cause readmission occurred in 47% of hospice-eligible patients and 1% of hospice-referral patients (HR, 0.03; 95% CI, 0.04 to 0.21).
30-day readmission for HF occurred in 17% of hospice-eligible patients and 2% of hospice-referral patients (HR, 0.14; 95% CI, 0.05 to 0.40).
90-day all-cause readmission occurred in 59% of hospice-eligible patients and 13% of hospice-referral patients (HR, 0.18; 95% CI, 0.12 to 0.29).
Among patients who died within 90 days of discharge, 3-month all-cause readmission occurred in 56% of hospice-eligible patients and 7% of hospice-referral patients (HR, 0.15; 95% CI, 0.07 to 0.31).
6-month all-cause readmission occurred in 64% of hospice-eligible and 18% of hospice-referral patients (HR, 0.18; 95% CI, 0.12 to 0.28).
Although mortality at 30 days was higher among the hospice-referral group compared with the hospice-eligible group (43% vs 27%), mortality was similar for both groups at 90 days (64% vs 67%).

“By 90 days post-discharge, mortality rates were similar between the groups and as a result, hospice referral was also associated with a significantly lower risk of the combined end point of 90-day all-cause readmission or 90-day all-cause mortality,” note the authors.

As HF progresses, patients commonly experience steadily worsening symptoms, as opposed to the periods of relative stability interrupted by acute exacerbations they experienced earlier in the disease course. Patients and families often lack prognostic awareness, point out the authors, and symptoms such as worsening dyspnea may prompt them to seek help from acute care facilities.

Among the many benefits of hospice is that the enrollment process includes explicit discussion of prognosis and goals of care, so that patients know what to expect and can choose how they want to be treated. Hospice care also aims to address dyspnea and other symptoms common in end-stage HF, such as pain, anxiety, and depression, the authors note.

“The substantially lower readmission rate in the hospice-referral group in our study suggests that the palliative care approach used by hospice teams may have been effective in alleviating HF symptoms, thus obviating needs for readmission,” they write.

Yet many patients with HF are not referred to hospice, or are referred too late to benefit from the comprehensive palliative approach. “National estimates suggest that hospice median length of stay is only 19 days overall and 17 days for patients with HF, and that 35% of patients die or are discharged within seven days of hospice admission,” write the authors. They point out that most HF patients in their study who died within six months of hospital discharge did not even receive hospice referral.

“These findings suggest that a more accurate identification of hospice eligible patients and a more appropriate hospice-referral approach may potentially lower 30-day all-cause readmission for hospitalized patients with HF,” the authors conclude.

Source: “Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure,” Circulation: Heart Failure; July 2015; 8(4):733- 740. Kheirbek RE, et al; Veterans Affairs Medical Center, Washington, DC; Department of Medicine, George Washington University, Washington, DC; Department of Medicine, Georgetown University, Washington, DC.

VITAS and the Assisted Living Facility: A Partnership of Care

Tue, 12 Sep 2017 00:00:00 -0400

Your assisted living facility (ALF) is home to your residents, a place where they have formed relationships with peers and staff, where they know the traditions and day-to-day schedules, where the faces and spaces are familiar. This is where they want to be.

As the nation’s largest hospice provider, VITAS® Healthcare has the expertise, the staff and the specialized services to keep your residents at home—out of emergency rooms, hospitals and nursing homes—as they approach the end of life. Hospice care is most beneficial when it is provided for months, rather than weeks or days. In addition to managing pain and symptoms, hospice may allow a resident to enjoy a meaningfully longer and better quality of life. The added time can be a boon to families, offering an opportunity to address spiritual, financial, practical and relational matters.

How does VITAS’ clinical expertise keep residents at home?

Levels of care. VITAS offers unsurpassed service across all four levels of hospice care:
- Routine Home Care—available wherever the patient calls home
- Intensive Comfort Care® (continuous care)— medical management in the home for up to 24 hours per day when medically necessary can make the difference between a resident remaining in the community and being sent to the emergency department for treatment
- Inpatient Care—when medical needs cannot be managed at home
- Respite Care—allows for a brief inpatient admission to provide caregivers a “respite”; designed for patients being cared for by a family member; not applicable to assisted living residents
VITAS Telecare® 24/7 support. Our Telecare service provides immediate telephone access to a clinical expert in our Care Connection Center® who can assess your resident’s situation and provide medical advice. Nearly 200,000 after-hours calls are handled by VITAS clinicians each month.¹
Consistent and ongoing clinical care. An average of five-plus visits per week¹ by a member of the VITAS team (which includes a hospice physician, nurse, social worker, hospice aide, chaplain and team volunteer) provide extra support for residents and their families. This high volume of visits is often instrumental in averting medical crises.

Effective Pain Management

At VITAS, managing patients’ pain is the utmost objective. As a palliative care pioneer, our organization has developed effective pain management protocols that are customized for the individual resident—which is critical in an assisted living setting. In addition to addressing physical and medical issues, our interdisciplinary approach addresses spiritual and emotional needs as well.

Supporting Your Residents and Staff

Comprehensive clinical education. VITAS offers nearly 70 educational programs customized for assisted living community staff. Our CE presentations are open to all; for nurses and social workers they are approved for CE credits in accordance with state requirements. VITAS provides these credits at no cost.
ALF consultant. VITAS ALF consultants are available to visit facilities, answer questions about hospice, talk about death and dying and explain how VITAS cares for residents near the end of life.
Specialized care programs and benefits:

Veteran program
Alzheimer’s/dementia programs
COPD program
Multilingual staff
Jewish accreditation
Pet therapy
Music therapy
Massage therapy
“Living memorials” to honor a resident’s life
Anticipatory grief support during the illness
Bereavement support groups for families
Memory Bears

Ongoing Communication

The best partnership of care at the end of life is the result of ongoing communication between an informed resident, their family, their hospice team and the assisted living staff. Residents who understand the course of their illness and what to expect, and who have documented personal preferences in a living will or advance directive, are the ones most likely to receive hospice care according to their personal beliefs.² Finally, good communication improves patient/family satisfaction ratings.

Selecting a Strategic Partner

Choosing the right hospice partner is critical.

Look for:

Rapid response time; same-day admission seven days per week
Direct access to clinicians 24 hours per day, seven days per week
High-tech capabilities: rapid intake via iPad, interoperability with hospitals’ EMR, real-time exchange of patient information, VITAS app with eligibility guidelines
Ability to accept high-acuity patients
HIPAA-compliant case reviews with your team
Meetings with residents and their families for an information-only discussion of end-of-life care options
Extra support at the time of death, as well as formal bereavement and support groups
Specialized service options for assisted living communities, such as staff training, education and development of customized protocols

VITAS® Healthcare supports your residents’ desire to remain in their home even as their health declines. The most important step you and your staff can take is to proactively identify those at risk for a medical crisis.

¹Data on file at VITAS.

²bit.ly/1ejEQYG Journal of the American Geriatrics Society, online June 19, 2015

Cardiologists Urged to 'Champion' End-of-Life Care for Patients and Their Families

Wed, 14 Nov 2018 00:00:00 -0500

Clinicians caring for patients with advanced heart failure (HF) are encouraged not only to continue their focus on the quality of their own delivery of care as patients near the end of life, but also to advocate for changes to improve the overall care of this growing population.

This is according to the authors of an editorial commentary accompanying the study report from Gelfman et al published in JACC: Heart Failure.

“It is incumbent upon clinicians managing this vulnerable population to champion end-of-life care, including the principles of palliation and hospice,” write the authors, who are with the Duke University Medical Center and the Division of Cardiology, Duke University School of Medicine, Durham, NC.

Heart Failure Patients Should Receive Hospice Earlier

The Gelfman finding that 45% of HF patients who entered hospice died within seven days is of particular concern to the authors. “It seems unlikely that patients and their families derive the maximal potential benefit from hospice approaches when death occurs within seven days of enrollment,” they write.

The authors acknowledge the significant contribution of the Gelfman study to the knowledge base needed to shape future policy approaches to HF end-of-life care, and identify “several urgent needs for our patients and their families” highlighted by the study.

Actions Urgently Needed to Improve HF End-of-Life Care

The original, “one-size-fits-all” Medicare hospice framework designed to serve cancer patients must be updated and tailored to meet the needs of individuals with noncancer diseases, such as HF.
Similarly, Medicare’s six-month prognosis restriction should be re-examined and updated to accommodate the prognostication challenges inherent in organ failure diseases, particularly HF.
Clinicians should advocate for improved end-of-life care for HF patients. “We need to collectively improve communication about advanced care planning, changing goals of care, symptom management and bereavement,” the authors write. For example, evidence has shown that as chronic illnesses progress, patient goals often shift from life extension to enhancing quality of life, they note. “It is incumbent upon the HF practitioner to appreciate and anticipate these pivots in patient preference and [to] be as versed with comfort care strategies as we are with neurohormonal antagonists.”
The optimal location for HF patients’ death needs to be better understood, rather than assuming that because most polled patients say they would prefer to die at home, this setting is desired by or appropriate for all individuals with HF.
Payment models for hospice should be re-thought, particularly those models that form/present a barrier to hospice care for the subset of HF patients requiring interventions that hospice agencies find difficult to cover financially under the current system.
Clinicians need to listen carefully to patients and families in order to understand their needs and desires, and to ask themselves if they are providing the most extensive care their resources allow. “[W]e need to listen carefully to our patients and their loved ones,” write the authors. “What do they want at the end of life? Are we providing optimal care? Are we extending the full extent of our resources to assist family members? Should there be some longer- term commitment to survivor health?”

Source:

“It Is Time to Discuss Dying,” Journal of the American College of Cardiology: Heart Failure; September 2018; 6(9):790-791. Warraich HJ, Rogers JG; Department of Medicine, Division of Cardiology, Duke University Medical Center; and the Duke Clinical Research Institute, Durham, NC.

Hospice Patients Have Lower Hospitalization Rates, Reduced Medical Costs

Fri, 19 May 2017 00:00:00 -0400

Medicare patients with poor-prognosis cancer who enroll in hospice are significantly less likely than nonhospice patients to be hospitalized, admitted to an intensive care unit (ICU) or to receive invasive procedures near the end of life, according to a report published in JAMA Internal Medicine. Further, hospice patients have lower healthcare expenditures in the last year of life and are five times more likely than nonhospice patients with similar characteristics to die at home.

“Our study shows very clearly that hospice matters,” says lead author Ziad Obermeyer, MD, MPhil, of Brigham and Women’s Hospital and Harvard Medical School, Boston. “Hospice and nonhospice patients had very similar patterns of healthcare utilization right up until the week of hospice enrollment—then, the care started to look very different.”

“Patients who didn’t enroll in hospice ended up with far more aggressive care in their last year of life, most of it related to acute complications like infections and organ failure, and not directly related to their cancer diagnosis.” Such care is unlikely to match the end-of-life wishes of most patients, point out the authors.

Investigators analyzed data from a nationally representative 20% sample of 86,851 Medicare beneficiaries newly diagnosed with poor-prognosis cancer (e.g., lung, pancreatic, brain or any metastatic malignancy) who died in 2011. Patients who enrolled in and died while under hospice care were matched to a control group of those who died without hospice services, creating 18,165 matched pairs (mean age, 80 years) for the matched cohort study.

Overall:

Median length of time from first poor-prognosis diagnosis to death was 13 months (interquartile range, three to 34 months).
60% of patients were enrolled in hospice.
Median length of hospice stay was 11 days, with less than 6% of stays exceeding six months.

Key Findings

Compared with those in hospice, nonhospice patients had higher rates of:

Hospitalizations (65.1% vs 42.3%; risk ratio [RR], 1.5; 95% confidence interval [CI], 1.5 to 1.6)
ICU admissions (35.8% vs 14.8%; RR, 2.4; 95% CI, 2.3 to 2.5)
Invasive procedures such as intubation, dialysis or resuscitation (53.0% vs 26.7%; RR, 1.9; 95% CI, 1.9 to 2.0)
Death in a hospital or nursing facility (74.1% vs 14.0%; RR, 5.3; 95% CI, 5.1 to 5.5)
Healthcare expenditures during the last year of life ($71,517 vs $62,819; difference, $8,697; 95% CI, $7,560 to $9,835)

Nearly three-quarters of nonhospice patients died in hospitals or nursing homes, compared with just 14% of hospice patients. “These findings highlight the importance of honest discussion between doctors and patients about our patients’ goals of their care at the end of life relating to treatment decisions and quality of life,” says Obermeyer. This is particularly pertinent in light of the recent addition of reimbursement codes for advance care planning discussions by the Centers for Medicare and Medicaid, he notes.

Lower Costs

Enrollment in hospice was associated with a decrease in overall healthcare costs of $8,697 per patient during the last year of life. Patients enrolled for five to eight weeks represented the greatest cost difference ($17,903) compared with nonhospice patients, although shorter stays also resulted in lower, but still statistically significant, cost differences. Only among the 2% of patients who stayed in hospice longer than one year did expenditures exceed those of the nonhospice group.

“Cost trajectories began to diverge in the week after hospice enrollment, implying that baseline differences between hospice and nonhospice beneficiaries were not responsible for cost differences,” observe the authors. “Hospice enrollment of five to eight weeks produced the greatest savings; shorter stays produced fewer savings, likely because of both hospice initiation costs and need for intensive symptom palliation in the days before death.”

Hospice Stays Too Short

Median length of stay among hospice patients in the study was 11 days. As the number of patients with cancer who use hospice continues to rise, the length of hospice stays grows shorter, while care intensity outside of hospice is increasing, note the authors.

“Patients with cancer, the single largest group of hospice users, have both the highest rates of hospice enrollment and the highest rates of hospice stays of less than three days,” they point out. Since the initiation of the Medicare hospice benefit in 1982, the number of people of all diagnoses receiving its services has increased, yet the median length of stay has decreased over the same time period.

“We know that many people access hospice care too late to fully take advantage of all this team-based, patient and family-focused model of care can offer,” says J. Donald Schumacher, PsyD, former president and CEO of the National Hospice and Palliative Care Organization.

“While patients with cancer still make up more than a third of all those cared for by hospice providers, their lengths of stay in hospice are among the shortest. This points to the desperate need for clinicians treating cancer to have conversations about palliative care and hospice.”

Source: “Association between the Medicare Hospice Benefit and Health Care Utilization and Costs for Patients with Poor-Prognosis Cancer,” JAMA Internal Medicine; November 12, 2014; 312(18):1888-1896. Obermeyer Z, Makar M, Abujaber S, Dominici F, Block S, Cutter DM; Departments of Emergency Medicine and Health Care Policy, Harvard Medical School; Departments of Emergency Medicine and Psychiatry, Brigham and Women’s Hospital; Ariadne Labs; Department of Biostatistics, Harvard School of Public Health; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; Department of Economics, Harvard University, all in Boston.

How to Cope when Your Patient Dies

Wed, 01 Feb 2017 00:00:00 -0500

Living with Dying

“Some patients die. As a doctor, I have to live with this inevitable fact.”

Australian oncologist and author Dr. Ranjana Srivastava used these words to open a 2015 column on dealing with the death of a patient (The Guardian, March 20, 2015). Medical professionals working in a variety of specialties have different training and treatment protocols. But most have one thing in common—the death of a patient.

As common as it is, however, medical professionals don’t easily speak about the emotional toll. “’I lost a patient today’ attracted a unique brand of awkwardness among doctors,” writes Dr. Srivastava. Dealing with loss is not part of a physician’s training. Unlike patients’ loved ones, medical professionals often don’t have access to grief counseling; sometimes they don’t even have time to reflect on their feelings regarding the death. And, as these common misconceptions reveal, even the need to grieve is disparaged:

As a professional, I am trained not to be affected.
Grieving is unprofessional.
Just move on, there are other patients to serve.
My work is not personal.
I can’t do my work if I let myself grieve.

“The consolations of fulfilling a doctor’s obligations were familiar, but so were the exquisite and fragile emotions that accompanied the loss of a patient. It was as if a bit of grief always lurked in the corridors, springing out to hijack the unsuspecting soul. Sometimes you swiped it away, other times it overpowered you.” — Dr. Ranjana Srivastava

Research over the past four decades has identified potential adverse consequences affecting the health and well-being of professionals who fail to cope with their feelings following a patient’s death. They include stress, problems with physical health, depression, burnout and “compassion fatigue.” A theme that emerges from the studies is one of balancing emotional boundaries—growing close enough to care about the patient but remaining distant enough to avoid the pain of loss. Few professionals surveyed felt they had been able to do this effectively.

How to Cope

Some recommended coping strategies are self-explanatory: exercise, eat right, learn how to set limits, set aside time for yourself. Others are a bit less usual. But all can help medical professionals and their teams remain healthy during emotionally stressful times.

Seek the guidance of a trusted senior practitioner—Most have had this experience at some point in their career. They may be willing to offer their own insight and strategies for coping.
Be introspective—Determine what lessons can be learned that will help you and your team grow. Be open to feedback.
Support your team—Review the case with your team and allow everyone to have a voice in expressing what occurred.
Be there for the family—No matter how you or your staff are feeling, they have lost a loved one.
Seek the support of your family/friends—Mourn and seek comfort from family, friends, clergy, peers.
Consider attending the funeral—This will be based on the closeness of the relationship with the patient and the family. Some professionals find closure from the process. Families appreciate your presence.
Write a personal note to the family.
Reach out to a colleague who has lost a patient—Opening lines of communication can benefit you and your colleague.
Seek professional help—The death of a patient can lead to extreme stress. If a case troubles you deeply, consider discussing it with a counselor.

Medical professionals need to be responsible for their own care. An honest assessment of your ability to cope with loss, and of the toll it may already be taking, can help determine the right next steps for you.

“I knew that there was a point to grief, as a catalyst for improvement. Being a doctor is emotionally punishing, but connecting with our patients as fellow human beings is what renders it not merely a job, but an incomparable vocation.” — Dr. Ranjana Srivastava

Deprescribing: Discontinuing Medications Near the End of Life

Fri, 30 Aug 2024 04:00:00 -0400

How Hospice Patients May Benefit from Deprescribing

by Heather Veeder, MD, & James Wright, DO, VITAS Regional Medical Directors

Deprescribing starts with a conversation between a patient and their medical team that explores decreasing or discontinuing medications that are no longer helpful and may be harmful to the patient. This conversation should evaluate medications in the context of the patient’s goals and values, including answering medical questions and considering ethical issues involved in changing a patient’s medications near the end of life.

“Many patients are taking too many pills when they come to hospice,” says Dr. Heather Veeder, VITAS regional medical director. “While these medications and supplements have been helpful in treating or preventing disease, most of them are unhelpful or even harmful when a patient is sick enough to be in hospice care. Most of the pills end up sitting in the patient's stomach, taking up space, and our patients end up eating less than they would otherwise.”

Polypharmacy in hospice — the simultaneous use of multiple drugs by a single patient for one or more conditions — requires a reconciliation of all medications and products taken by the patient. Every statin and vitamin, every maintenance medication and OTC product should be assessed for appropriateness and impact as a patient nears the end of life:

Is it a high-risk medication?
What are its benefits?
Are its benefits important to the patient’s goals?
Is a benefit unlikely to be realized, given the patient’s limited life expectancy?
If a medication is prescribed for specific symptom or disease benefit(s), does its effect apply ... or is it non-existent?

“When we evaluate a patient's medications, we encourage them to take only what makes them feel better,” says Dr. Veeder. “We find that many of our patients do feel better when they aren't taking as many medications. Talking with our patients about whether a medication meets their goals can be a useful approach to the conversation.”

Explanations and Questions

High-Risk Medications to Reconsider in Hospice Care:

Blood thinners
Psychotropic drugs
Statins
NSAIDs
Anticoagulants
Digoxin
Cardiovascular drugs
Hypoglycemic agents
Anticholinergic agents
NSAID + diuretic
ACE inhibitor and chronic kidney disease drugs

Factors to consider include the patient’s terminal illness, co-morbidities, current status in the disease process, physiology, goals of care and more. Is the medication related to the patient’s advanced illness terminal prognosis? Is it intended to be palliative? Does it manage symptoms, or prevent ongoing progressive disease?

“One common example is cholesterol medicines like statins,” says Dr. Veeder. “Statins are designed to be long-term preventative medications, but they also have side effects like muscle pain. Discontinuing them can alleviate that pain, improving quality of life without compromising their care.”

Another example: When someone gets older or is nearing the end of life, tight glycemic control can be dangerous rather than helpful. At this point, patients may not need to take pills, perform finger sticks or inject medications, or monitor labs. Unnecessary disease management is replaced with life enjoyment in the time the patient has left.

Consistent Reviews Address a Patient's Evolving Needs

Once a patient is referred to hospice care, a typical transition involves changes in their healthcare team and care plan. Each patient’s medication regimen should be re-evaluated as well.

VITAS relies on the admissions RN (ARN) to explain the plan of care to a new patient and their family.

“The ARN addresses these questions with the family and the physician so that there are no surprises,” says Dr. James Wright, VITAS regional medical director. “Then, during weekly VITAS team meetings, the patient’s meds are re-examined. Dying is a process and can be quite complex. A patient may experience lower blood pressure or lose the ability to swallow, for example. Throughout the process, we continue to tailor the meds to the patient’s physiology and general condition.”

Involving Patients and Families in Decisions Around Deprescribing

Deprescribing can be an emotionally charged subject, and considerations may not be based solely on clinical data. Patients and families might feel abandoned by their doctors, for example, when a hospice physician determines that a prescription they thought was keeping them alive or making symptoms tolerable is unnecessary.

When the decision-making process includes patients and families, the outcomes are better. This process begins with empathetic communication from the physician. Learning tools that help healthcare professionals talk more effectively to patients about terminal illness and goals of care can apply to deprescribing as well. We recommended these three articles:

Risk vs. Benefit of Deprescribing

“When a patient or family is anxious about discontinuing medication, we have a risk-vs-benefit discussion,” says Dr. Veeder. “We ask, ‘What are the risks? What are the benefits? How does the medicine make the patient feel? Is it still needed?’ Every patient is different. The bottom line is always, is it a palliative intervention?”

Discussions about deprescribing are not reserved exclusively for patients and families. Hospice physicians consult with a patient’s primary care clinician and other specialists who have been actively engaged in managing care to provide the best possible care for the patient. Some medications that were previously deemed essential can be discontinued.

And while the concept of deprescribing medications can be unfamiliar to many clinicians, most understand that they are not experts in end-of-life care. They often refer and defer to the judgment of the hospice physician.

By deprescribing, hospice physicians ensure that end-of-life medications (or the absence of them) help patients live better. In the months, weeks, or days they have left, patients can experience fewer side effects, more alertness, less pain, and improved quality of life.

Is It an Emergency? Or Is It Hospice?

Wed, 16 Dec 2020 05:00:00 -0500

7 Things to Know About Advance Directives for Your Patients

Mon, 05 Apr 2021 04:00:00 -0400

The most effective strategy for identifying what your patients with advanced illness want near the end of life is to have goals-of-care conversations early, regularly, and matter-of-factly.

VITAS can help. So can these seven key points about advance directives, the written documents that outline a person's healthcare preferences:

Everyone over 18 should have advance directives. The most common types of advance directives include a living will, durable/medical power of attorney for healthcare decisions, Five Wishes document, and Physician/Medical Orders for Life-Sustaining Treatment document. Download advance directives and instructions for your state >
Advance directives give patients control of their medical care if they can’t communicate or speak on their own.
Advance directives are billable. Medicare reimburses up to $86 to discuss end-of-life care with patients.
The conversation is easier when the patient is healthy and alert. Ideally, families should be involved in the conversation to explore values, preferences and goals for care.
Advance directives can be modified over time.
Your patients are waiting for you to start the conversation. Ninety-two percent of people surveyed indicated they would be at least somewhat comfortable talking with a doctor or health care provider about their end-of-life medical wishes, including two-thirds (66%) who say they’d be very comfortable.¹
People who document their healthcare preferences in an advance directive are more likely to get the care they prefer at the end of life.²

Download a PDF of these tips >

Updated from an earlier version published on April 3, 2017.

¹Hamel, L. (2017). Views and experiences with end-of-life medical care in the US. The Henry J. Kaiser Family Foundation. Retrieved from: https://canceradvocacy.org/wp-content/uploads/Report-Views-and-Experiences-with-End-of-Life-Medical-Care-in-the-US.pdf

²National Institute on Aging. (2018). Advance Care Planning: Healthcare Directives. https://www.nia.nih.gov/health/advance-care-planning-health-care-directives

How to Spiritually Care for Your Patients Near the End of Life

Thu, 19 Oct 2017 00:00:00 -0400

As a healthcare professional, you know that spiritual care is valuable at any time, for any patient. At VITAS, we've found it's particularly essential for hospice patients as they struggle with apprehensions about their own death.

Social workers make a big difference by bringing psychosocial and emotional support to patients and families, but they can look after their patients’ spiritual well-being as well by assessing their spiritual needs and connecting them to people, literature and other resources that can help.

3 Ways to Help Your Patients with Spiritual Guidance

Ask about their faith, or lack thereof. If they belong to a church or synagogue, encourage them to connect with fellow congregants and their pastor or rabbi. Patients and families sometimes “don’t want to be a bother” to others and need encouragement to reach out.
Look in the bookstore or online for patient-oriented books on death and dying. Learn a little bit about your patient’s (or their loved one’s) beliefs and interests before you buy or recommend. There is a plethora of books on death and dying, from the humorous (“Can We Talk About Something More Pleasant” by Roz Chast) to the deeply philosophical (“Advice on Dying” by the Dalai Lama) and many others in between.
Ask the VITAS care team manager for a referral. Most VITAS care teams include numerous spiritual leaders and volunteers who can lend spiritual support.

VITAS Chaplains and Bereavement Specialists Provide Spiritual Care

Specialized spiritual care is built into the interdisciplinary VITAS care team. VITAS chaplains are always available to support patients and grieving families with counseling appropriate to any faiths—and no faith.

Our bereavement specialists help patients and families cope with grief and loss. They are there for families for months after a death, and can provide one-on-one support, support groups and grief education.

Hospice Cardiac Care Is Aggressive, Palliative Symptom Management

Wed, 14 Nov 2018 00:00:00 -0500

By James Wright, DO, Regional Medical Director, VITAS Healthcare

It is often stated that heart failure is difficult to prognosticate, resulting in just 4.9% of Medicare patients hospitalized with advanced heart failure receiving hospice referrals. And those patients are referred exceptionally late in the trajectory of their disease, according to “Trends in Hospice Discharge and Relative Outcomes Among Medicare Patients in the Get With the Guidelines^®Heart Failure Registry.

Hospice mortalities demonstrate the late nature of HF referral. In this study, most hospice patients (66%) died within 30 days of referral; almost one in four HF patients died in the first three days after referral to hospice. Only 15% lived six months or more. Few patients who received hospice—4.1%—were readmitted to the hospital within 30 days.

Better tools, better management

The study’s authors believe that clinicians may benefit from better tools to assess prognosis in HF, so that timely referrals to palliative care and hospice can be made. They also believe that better management of symptoms might lead to improved transition to hospice.

However, we already know who the hospice-eligible HF patients are. The American Heart Association (AHA) and American College of Cardiology (ACC) have provided the tool: a heart-failure staging system from A through D. Stage D describes patients with advanced structural heart disease and progressive symptoms at rest who are already receiving optimum medical management.

If the Stage-D patient is not a candidate for, or does not choose, heart transplant, ventricular assist devices (VAD) or other cardiac surgical options, then, by definition, all options for treatment have been maximized.

This definition allows providers, HF patients and families to advance care to the next therapeutic level: hospice.

Aggressive and palliative hospice care

Hospice cardiac care is aggressive, palliative symptom management. It may include therapies such as maximized use of cardiac medications that are already in place, continuous infusion of inotropes, and further comfort care measures in the environment of the patient’s choosing.

“Palliative” and “aggressive,” it should be noted, are not mutually exclusive terms. We must end the misunderstanding that palliation of symptoms means giving up. Hospice is not giving up. It is refocusing on the patient—on their physical, spiritual and emotional needs—and on their family, rather than exclusively on the disease.

Months before a patient with advanced structural heart disease is hospitalized, referral to hospice can initiate aggressive, palliative symptom management while patients and their families still have the time and the will to enjoy quality of life.

One day, better management of advanced cardiac disease may mean better management of symptoms, with the optimum scenario being palliation of symptoms under hospice care.

4 Levels of Hospice Care For Your Patients with End-of-Life Care Needs

Fri, 15 Dec 2017 00:00:00 -0500

The Medicare Hospice benefit covers 4 levels of care for your hospice-eligible patients. Medicare payments for each level include all services, medications, equipment and supplies related to the terminal illness. VITAS has services and resources to provide care at all 4 levels.

VITAS can transition your eligible patients to hospice care so they can take advantage of all covered services and supplies.

Routine Home Care

The majority of hospice services are provided via routine home care. In 2015, 98.7% of hospice care provided was in this category. Routine home care includes scheduled, routine visits in the home by a multidisciplinary care team, including hospice physician, registered nurse, hospice aide, social worker, chaplain, volunteer and bereavement specialist. “Home” is defined as the patient’s residence, which may be a private home, assisted living facility or nursing facility.

Continuous Home Care

Continuous home care brings shifts of acute symptom management to the patient’s bedside for up to 24 hours/day per Medicare guidelines. At VITAS, we call this Intensive Comfort Care^®.

Inpatient Care

When acute or chronic pain or other symptoms cannot be managed in the home, or when attempts at management have been ineffective, inpatient care provides round-the-clock care in a Medicare-certified hospice bed in the hospital, a dedicated hospice inpatient facility or a nursing facility. Patients return to their homes and routine home care when symptoms stabilize.

VITAS can transition your eligible patients to hospice care so they can take advantage of all covered services and supplies.

Inpatient Respite Care

Primary caregivers are at risk for burnout—respite care can provide a temporary break. Hospice patients receive 24-hour care in a Medicare-certified hospital, hospice facility or long-term care facility for up to 5 days.

Hospice Enrollment Linked to Symptom Burden, But Care May Often Begin Later Than Needed

Tue, 14 Nov 2017 00:00:00 -0500

As restricting symptoms increase and the functional status of older adults nearing the end of life declines, the likelihood of hospice referral rises, researchers have found. But because the median hospice stay is just 12.5 days, many patients experience distressing symptoms and disabilities for months prior to the start of hospice, according to a report published in Journal of the American Geriatrics Society.

“Hospice services appear to be suitably targeted to older persons with the greatest needs at the end of life, although the short duration of hospice suggests that additional strategies are needed to better address the high burden of distressing symptoms and disability at the end of life,” write the authors. “In an earlier study, we found that the number of restricting symptoms at the end of life decreased significantly after the start of hospice.”

15-Year Study

Investigators analyzed data on the last year of life for decedents (n = 562) from an ongoing longitudinal study of 754 community-dwelling older adults (aged ≥ 70 years) who were nondisabled in activities of daily living (ADLs) when enrolled from 1998 to 1999. Follow-up via home-based assessments every 18 months and monthly telephone interviews with participants or their proxies were conducted through 2014.

During follow-up interviews, participants were assessed for the presence of any of the following restricting symptoms: fatigue; musculoskeletal pain; dyspnea; chest pain or tightness; nausea, vomiting or diarrhea; depression; anxiety; arm or leg weakness; difficulty sleeping; dizziness or unsteadiness; difficulty with memory or thinking; swelling in feet or ankles; cold or influenza symptoms; poor or decreased vision; and urinary frequency, pain or incontinence.

Participants were also assessed for the presence of any disabilities in the previous month in the following ADLs:

The basic activities: bathing, dressing, walking, transferring
The instrumental activities: shopping, housework, meal preparation, taking medications, managing finances
The mobility activities: walking 1/4 mile, climbing a flight of stairs, lifting and carrying 10 pounds, driving a car

Overall

43.4% enrolled in hospice during the last year of life.

Median hospice length of stay was 12.5 days (interquartile range, 4 to 43 days), with no significant differences regarding the condition leading to death.

Key Findings:

During a specific month, the likelihood of hospice enrollment increased by 66% in the setting of any restricting symptom (adjusted hazard ratio [aHR], 1.66; 95% confidence interval [CI], 1.30 to 2.12) and by 9% for each additional restricting symptom (aHR, 1.09; 95% CI, 1.05 to 1.12).
Further, each additional month with any restricting symptoms increased the likelihood of hospice enrollment by 7% (aHR, 1.07; 95% CI, 1.01 to 1.13).
The likelihood of hospice entry increased by 10% (aHR, 1.10; 95% CI, 1.05 to 1.14) for each additional disability during a specific month.

“Our results suggest that decisions about hospice admission at the end of life are based, at least in part, on the presence and burden of restricting symptoms and disability,” write the authors.

“In absolute terms, the average probability of hospice admission was 15% higher in the last year of life for participants who had any restricting symptoms in a specific month than for those who did not.”

However, both the prevalence and mean number of restricting symptoms began to rise at six months before death, well before patients’ referral to hospice, note the authors.

Symptom Burden Should Inform Hospice Referral

“Because hospice is designed to ameliorate pain and other distressing symptoms, referral to hospice should be based, at least in part, on the burden of these symptoms, but the short duration of hospice, coupled with preliminary data from our group, suggest otherwise.”

The finding of short hospice stays, suggesting late referrals, is cause for concern, according to the authors. They suggest that hospice may be underused among older adults because many physicians “may not weigh the burden of disability in their decision-making about hospice referral, despite evidence that functional status is one of the strongest predictors of mortality in older persons.

“Our focus on symptoms leading to restricted activity and disability in basic, instrumental and mobility activities enhances the clinical relevance of our findings because proper management of these symptoms and disabilities may substantially improve quality of life while reducing caregiver burden.”

Source: “Beyond Code Status: Palliative Care Begins in the Emergency Department,” Annals of Emergency Medicine; April 2017; 69(4):437-443. Wang DH; Department of Emergency Medicine, Stanford University, Stanford, California; and Division of Palliative Medicine, University of California-San Francisco, San Francisco.

High Symptom Burden Among Hospitalized Patients with Advanced Cancer Linked to Longer Stays, Risk of Readmission

Mon, 14 May 2018 00:00:00 -0400

A heavy physical and psychological symptom burden is experienced by hospitalized patients with advanced cancer; many of their symptoms—which are potentially manageable—are significantly associated with hospital length of stay (LOS) and risk of unplanned readmission within 90 days of discharge, a team of Harvard researchers has found.

“Our work represents the largest study to date highlighting the immense symptom burden of hospitalized patients with advanced cancer,” write the authors of a report published in Cancer, a journal of the American Cancer Society. “To our knowledge, this is the first study to demonstrate the relation between patients’ self-reported physical symptoms and healthcare utilization among hospitalized patients with advanced cancer.”

Patients Want to Remain Home

Currently in the U.S., more than one-half of cancer patients are hospitalized at least once during the last month of life and nearly 10% have a hospital readmission during that period, despite the preference of most patients with advanced cancer to avoid hospitalization and remain at home, the authors note.

Although most research on cancer patients’ symptom prevalence and severity has focused primarily on those in the outpatient setting, hospitalized patients with advanced cancer often experience a higher symptom burden than those in the ambulatory care setting. “There is a critical need to determine the efficacy of supportive care interventions in this population to reduce symptom burden,” write the authors.

Investigators analyzed inpatient symptom-burden questionnaire responses of 1,036 adult patients with advanced cancer not receiving curative treatment who had unplanned hospitalizations between 2014 and 2015. Physical and psychological symptoms of the patients (median age, 63.4 years; male, 50.6%; white, 92.4%) were assessed using the self-administered, revised Edmonton Symptom Assessment System (ESAS-r) and the Patient Health Questionnaire 4 (PHQ-4), respectively.

Overall:

A large majority of participants reported symptoms of moderate-to-severe fatigue (86.7%), poor well-being (74.2%), drowsiness (71.7%), pain (67.7%) and lack of appetite (67.3%).
Only 1.7% reported experiencing no moderate/ severe symptoms.
More than one-quarter of patients had clinically significant symptoms of depression (28.8%) and anxiety (28.0%).
Mean hospital LOS was 6.3 days.
Rate of hospital readmission within 90 days was 43.1%.
90-day mortality rate was 41.6%.
Nearly two-thirds (65%) died or were readmitted within 90 days.

After adjusting for potential confounders— including comorbidity, cancer type and time since the diagnosis of advanced cancer—symptom burden remained a significant predictor of healthcare use. “It is important to note that patients’ symptoms represent a potentially modifiable risk factor that, if properly addressed, may improve healthcare quality and delivery,” the authors point out.

Key Findings:

LOS: Patients’ physical symptoms (P < 0.001), total symptom burden (P < 0.001), total psychological distress (P = 0.040) and symptoms of depression (P = 0.017) were all significantly associated with longer hospital LOS.
Readmission: Physical symptoms (P < 0.001), total symptom burden (P < 0.001) and anxiety symptoms (P = 0.045) were significantly associated with a higher risk of 90-day readmission.
90-day death or readmission: Physical symptoms, total symptom burden, total psychological distress and depression symptoms (all, P = 0.001) were significantly associated with a higher likelihood of death or readmission within 90 days, as were symptoms of anxiety (P = 0.012).

ID and Treat the Patient

“Most, if not all, of the symptoms identified are treatable with intensive supportive care measures that can be feasibly implemented, especially during hospital admissions,” write the authors. “Interventions to identify and treat symptomatic patients hold great potential for improving patients’ experience with their illness, enhancing their quality of life and reducing their healthcare utilization.”

Generalizability of their findings to other populations may be limited by the low rate of socioeconomic diversity in their study sample, note the authors. Nevertheless, “Our investigation provides novel insights to help clinicians and policymakers critically assess the potential contribution of uncontrolled symptoms to excessive and costly cancer care.”

Source: “The Relationship between Physical and Psychological Symptoms and Health Care Utilization in Hospitalized Patients with Advanced Cancer,” Cancer; December 1, 2017; 123(23):4720-4727. Nipp RD, El-Jawahri A, Temel JS, et al; Department of Medicine, Division of Hematology and Oncology; and Department of Medicine, Division of Palliative Care, Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston.

Why Don't More Healthcare Professionals Have End-of-Life Directives?

Fri, 12 Jan 2018 00:00:00 -0500

Based on healthcare professionals’ firsthand experiences with patients, it stands to reason that they would be highly motivated to create end-of-life (EOL) care plans for themselves.

The plans, also called advance directives, would tell loved ones and healthcare providers exactly how they feel about end-of-life (EOL) care and who will make decisions for them if they are unable to do so themselves.

However, studies and surveys show the general public embraces advance directives at rates greater than healthcare professionals. In one Kentucky ICU, only 13% of the team members have formal EOL care plans. Among the general public, 39% have a living will and 33% have appointed a power of attorney for healthcare.

Take action today: A step-by-step guide to your advance directives

EOL experts recommend taking these steps now to make sure your wishes are known and carried out if you are diagnosed with a terminal disease or are approaching death and cannot speak for yourself:

Learn about the end-of-life care options available to you, including how to start the conversation.
Ask hard questions and then decide for yourself what kind of care you want, and which interventions or treatments you do not want.
Discuss your wishes about death and dying with your family, loved ones, partner, healthcare provider, and the person you've designated as your healthcare power of attorney.
Put your wishes in writing so your choices are clear to everyone involved; make sure a written copy is included in your medical record or chart. Download state-specific forms to start the process.
Distribute copies of your advance directives to family members and anyone who will be involved in end-of-life decisions, including your doctor and members of your healthcare team.

Five Wishes is a living will that uses plain language (in any language) to spell out your medical, personal, emotional and spiritual wishes near the end of life. It is available from the non-profit group Aging With Dignity. Check to make sure the Five Wishes document is valid in your state; some states require additional forms or notices for it to be recognized.

Moreover, a 2013 Stanford University survey found that while the majority of physicians would take aggressive action to save their patients’ lives, nearly nine in 10 would choose do-not-resuscitate (DNR) orders for themselves in the event of a medical crisis, injury or terminal diagnosis—perhaps because they are acutely aware of the side effects, costs and negative consequences of feeding tubes, breathing tubes and other EOL interventions.

Which raises the question: If they know what they want (and do not want), why don’t they put their wishes in writing?

What’s holding healthcare professionals back?

A variety of dynamics are at work among healthcare professionals who have not formalized their EOL wishes:

Because they deal with illness and disease daily, many are not yet ready to confront death and dying for themselves
Some have discussed EOL issues or healthcare power-of-attorney designation with a spouse/partner and family members, but have not put their own wishes in writing
Some receive little or no training about how to talk to patients about palliative care, death and dying—a gap that is likely to spill into their own decision-making process
Cultural influences might play a role; a 2017 study found that members of non-Western cultures often delay EOL planning because of a sense of fear or inappropriateness attached to the topic of death
Physicians specializing in emergency medicine, pediatrics, obstetrics-gynecology, and physical medicine/rehabilitation are more favorable toward advance directives, compared to specialists in radiology, surgery, orthopedics and radiation oncology, according to the Stanford survey

Get started: Confirm EOL wishes, designate a decision maker

Advance directives typically involve two common and easy-to-execute documents:

A living will, which indicates the types of care a patient wants (and does not want) when facing a medical crisis or death, especially if the patient is unable to communicate
A durable power of attorney for healthcare, which designates someone who will speak and decide for the patient in accordance with the patient’s values and wishes

Healthcare professionals—whether placing a patient in an appropriate hospice setting or performing brain surgery—make life-and-death decisions all the time.

But if they lack a formal end-of-life plan for themselves, or if they avoid frank discussions about advance directives, they create situations in which their loved ones and doctors are forced to make critical decisions in less-than-ideal circumstances. Lacking clear guidance, their own doctors might decide to treat as they see fit, regardless of the patient’s wishes. Families and caregivers might choose more aggressive (and unwanted) treatment options, especially if they are conflicted about the patient’s wishes or if their values are at odds with the patient’s.

End of life: a delicate and complicated subject to start discussing now

Yes, discussing death and dying can be difficult and emotionally unsettling.

But advance directives are the surest way to make certain that decisions about your own life and death—made at a time of mental clarity—are carried out according to your wishes and values.

Clinical Guidelines Urge Early Hospice Discussion for Patients with Advanced Cancer

Fri, 23 Aug 2024 04:00:00 -0400

By Ileana Leyva, MD, Regional Medical Director, VITAS Healthcare

The American Society of Clinical Oncology (ASCO) has reviewed and upheld its 2017 consensus guideline for patient-clinician interventions and communication in advanced cancer care, with a focus on clear and empathic conversations with patients and their families throughout the illness course, from diagnosis to consideration of end-of-life care.

Cancer clinicians are advised to ensure patient understanding of prognosis and treatment options, establish clear care goals based on patient values and priorities, and initiate discussion of palliative care, including hospice care for the last six months of life, immediately following an advanced cancer diagnosis, according to the updated guideline, which was published in the Journal of Clinical Oncology in 2024.¹

Guiding patients who are living with advanced cancer through this journey to maintain hope while also clearly communicating accurate diagnostic information can be challenging for oncology clinicians. However, improving these communication skills will create a better care experience for both patients and their families.

Summary of Recommendations from Update

ASCO first convened a multidisciplinary panel of experts in fields such as medical oncology, hospice and palliative medicine, psychiatry, nursing, communication skills, and health disparities to develop best-practice recommendations based on a systematic review of the medical literature from 2006–2016 and formalized through a consensus process.

The authors of the original report stated effective communication skills enhance the well-being of clinicians, patients, and their families². “When providers understand who their patients are, what they want from their life and their cancer treatment, and how they make decisions, patients are empowered,” they wrote.

Researchers for the 2024 ASCO Guideline Update published in the Journal of Clinical Oncology¹ offer the following recommendations:

Clinicians should refer patients with advanced solid tumors and hematologic malignancies to specialized interdisciplinary palliative care teams that provide inpatient and outpatient care early in the course of disease, alongside active treatment of their cancer.
Among patients with cancer with unaddressed physical, psychosocial, or spiritual distress, cancer care programs should provide dedicated specialist palliative care services to complement existing or emerging supportive care interventions.
Clinicians from across the interdisciplinary cancer care team may refer the caregivers (including family, chosen family, and friends) of patients with cancer to palliative care teams for additional support.
For patients with advanced cancer, the Expert Panel recommends early specialist palliative care involvement, especially for patients with uncontrolled symptoms and/or quality-of-life (QOL) concerns.
Clinicians should refer patients with hematologic malignancies to specialist palliative care.
Clinicians caring for patients in early-phase clinical trials, including phase I, may refer patients to specialist palliative care to assess and address the needs of patients with advanced solid tumors.

Three Suggested Communication Strategies

Prognosis and Goals of Care

Tailor diagnostic and prognostic information to the patient’s needs, providing hope and reassurance while not misleading the patient. Triggers for discussions of prognosis and goals of care include initial diagnosis, relapse or disease progression, change in patient goals or treatment approach, and patient/family request.

Assure the patient that as their clinician, you will do everything you can to ensure the best possible outcome. “I will do everything I can to support you.”
Express solidarity. “I wish I had better news.”
Avoid minimizing bad news or changing the subject. Pause. Wait for the patient’s response, then respond empathically and encourage questions.

Treatment Options

Discuss all treatment options—including clinical trials and palliative/hospice care— in a way that facilitates understanding, promotes autonomy and preserves patient hope.

Determine whether the patient’s values and preferences have changed since the last conversation.
Frame the treatment options in the context of these goals and priorities.
Focus on what can be done; acknowledge uncertainty.
Reinforce that the patient will not be abandoned. “I will continue to take care of you, whatever happens.”

End-of-Life Care

Hospice eligibility is defined by disease states. Oncology practice guidelines, for example ASCO guidelines, indicate patients who are living with advanced cancers, such as stage three and four that are metastatic and have not been responsive to first-line anti-tumor therapies, may be hospice eligible now.

Other indications include a compromised performance status of spending 50% or greater of time in a chair or bed and having disease progression through first-line chemotherapy and/or numerous symptoms such as pain, shortness of breath, fatigue, nausea.

Initiate discussion of end-of-life care preferences early in the course of incurable cancer and revisit the topic periodically.

Introduce hospice by aligning the patient’s goals and needs with the treatments and services that hospice care provides. “I understand that you don’t want to spend any more time in the hospital, but you are scared about pain control at home. There is a group of services called hospice, covered by Medicare, that can help you stay at home and manage your pain and other symptoms.”
Explain that with hospice, an active plan of care focuses on identifying the patient’s goals of care, wishes, and values. Then translating these into a plan of care that reflects what the patient wants, ensuring that they and their family fully understands the illness, treatments, and interventions that individualize the plan of care while optimizing quality of life. Hospice minimizes unnecessary suffering while providing whole person-, patient-, and family-centric care.
Refer to published protocols such as SPIKES, which may be helpful in guiding end-of-life conversations. Revisit this conversation when triggers including illness progression, functional decline, increased high-intensity healthcare utilization, and/or consideration of high-risk or high-burden interventions are present.

Having honest, timely dialogue with these patients and their families allows them to make the best possible decisions for themselves.

Additional resources are available to support your conversations about end-of-life care with patients. The VITAS Goals of Care Preceptorship program offers clinicians the essential tools and techniques to facilitate meaningful and compassionate discussions with patients and their families. Learn more.

¹Sanders, J. et al. (2024). Palliative Care for Patients With Cancer: ASCO Guideline Update. Journal of Clinical Oncology. 42, 2336-2357(2024). DOI:10.1200/JCO.24.00542

²Gilligan, T. et al. (2017). Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. Journal of Clinical Oncology. 35(31):3618- 3632.

This article was originally published in 2018 and updated on August 22, 2024.

How Hospice Workers Can Overcome Compassion Fatigue

Tue, 07 Nov 2017 00:00:00 -0500

Compassion can be a risky business.

Professionals who care for patients with serious illness should have a well-developed sense of empathy, but continuous compassion without sufficient self-care can harm even the best-intentioned healthcare professional. Fear, grief, conflict and desperation are common features near the end of life; these emotions are contagious, and the clinician is not immune.

Signs of Compassion Fatigue

Compassion fatigue has been called “a deep physical, emotional and spiritual exhaustion accompanied by acute emotional pain.” It can appear differently for everyone, but common symptoms of compassion fatigue include¹:

Anger
Depression or anxiety
Gastrointestinal problems
High blood pressure
Addictive behaviors
Difficulty sleeping
Physical or emotional exhaustion
Irritability
Diminished self-esteem

Coping and Self-Care Strategies

Ideally, healthcare professionals should have what researchers call “compassion satisfaction”—a sense of joy that comes from helping others. Compassion fatigue is a well-known occupational hazard; self-care can turn up the satisfaction quotient. Aside from the usual stress-busting techniques (exercise, creating boundaries, etc.), some other methods have been shown to help compassion fatigue specifically.

Self-Awareness

Research has shown that highly conscious engagement with patients and situations—moment to moment—could help protect healthcare professionals from compassion fatigue. The idea is to pay close attention to one’s own emotions and reactions (the internal reality) while consciously working to address the needs of others (the external reality). This mindful way of working, along with mindful meditation and journaling, has been shown to reduce stress, enhance well-being and increase empathy in healthcare professionals.²

Rituals

In an online survey of hospice staff across 38 states, 71% of respondents reported using personal rituals such as lighting candles, praying, attending funerals and calling patients’ family members. Professionals who established rituals around their patients’ deaths scored higher on a compassion-satisfaction scale and lower on a burnout scale.³

Don’t skip the usual antidotes to compassion fatigue—eat well, rest well, get a little cardio into your day—but do add some mindful activities to keep yourself on an even keel. Then, be the rock everyone else needs to lean on.

¹Pfifferling, et al. Overcoming compassion fatigue. Fam Pract Manag. 2000;7(4):39-44

²Kearney, et al. Self-care of physicians caring for patients at the end of life. JAMA. 2009;301(11):1155-1164.

³Montross-Thomas, et al. Personally meaningful rituals: A way to Increase compassion and decrease burnout among hospice staff and volunteers. J Palliat Med. 2016;19(10):1043-1050.

COPD Patients Need the Support of Proactive Palliative Care

Wed, 16 Aug 2017 00:00:00 -0400

“Primary care providers [and] specialty pulmonologists should be … capable of screening patients who would benefit from proactive outpatient supportive care: … nursing, social work, respiratory, physical and pastoral.” —Vermylen et al, International Journal of Chronic Obstructive Pulmonary Disease

The Importance of Meeting the Needs of COPD Patients

Patients with chronic obstructive pulmonary disease (COPD) are frequently under-supported, experiencing significant symptom burden, disability, and quality of life impairment during the last few years of life. They also aggressively use healthcare resources near the end of life, according to an article published in the International Journal of Chronic Obstructive Pulmonary Disease.

“Despite refractory symptoms and recurrent hospitalization, many patients with COPD die without access to palliative care,” write the authors, a team of experts in hospice and palliative medicine and pulmonary disease from Northwestern University Department of Medicine, Chicago.

The authors urge the practice of “proactive primary palliative care”—the incorporation of palliative care into the routine management of COPD. Their article offers a framework for the provision of palliative care and includes a list of triggers for when to initiate or escalate palliative care interventions.

“Primary care providers as well as specialty pulmonologists should be trained and capable of screening patients who would benefit from proactive outpatient supportive care,” they write. “Interdisciplinary teams, including nursing, social work, respiratory and physical therapists and chaplains or pastoral care should be engaged to meet the complex needs of their patients.”

COPD, a chronic and frequently disabling disease for which there is no cure, is the fifth leading cause of death worldwide, point out the authors. Unlike heart disease and stroke, which have seen mortality rates decrease in recent years, COPD is increasing in prevalence and its symptom burden is heavy.

“The burdens of significant symptoms and comorbid health conditions in COPD are comparable to or worse than other chronic illnesses, including heart failure, HIV and metastatic cancer,” write the authors. “Patients with COPD, however, are less likely to have adequate treatment of symptoms at the end of their life, are more likely to have a decreased health-related quality of life, and are significantly less likely to receive specialist palliative care referral.”

Burdens of COPD:

Disability. COPD is the 11th leading cause of disability worldwide and is projected to be the seventh leading cause by 2030.
Shortness of breath. Breathlessness is a distressing symptom in itself and one associated with decreased quality of life and greater risk for further exacerbations and functional decline. Nearly all COPD patients, even those with stable lung function, report shortness of breath.
Fatigue, cough and pain.
Depression and anxiety. These symptoms often go unrecognized and unaddressed.

Palliative care has been found to improve symptom burden, quality of life and patient satisfaction in patients with COPD, the authors note. In its 2008 official policy statement on palliative/hospice care, the American Thoracic Society recommended that palliative services be available to patients with respiratory diseases “at all stages of illness.” However, delivery of these services to COPD patients is still far from the norm, due to persistent barriers.

Barriers to timely palliative care provision:

Prognostication. Because COPD patients typically experience a slow decline punctuated by episodes of acute exacerbation—many of which the patient will survive—recognizing the terminal phase of COPD is extremely difficult for physicians, patients and their families, the authors note.

The authors recommend a care approach that does not rely on precise prognostication and the identification of imminent death, but that instead proactively provides early access to palliative services.

Communication. Physicians may tend to avoid conversations with COPD patients about palliative and hospice care due not only to the difficulty in determining prognosis, but also because of a perception of inadequate training or time for holding such discussions. Further, some physicians may view palliative care as a service appropriate only for the actively dying, and fear they may take away a patient’s hope by introducing the topic “too early.”

Patients may prefer not to think about or discuss the end of their lives, or feel uncertain which physician they should talk to. But many COPD patients want emotional support and the peace of mind of knowing their suffering will be addressed and their wishes respected.

Palliative care triggers:

Triggers for initiating or intensifying palliative care resources for COPD patients:

Advanced age (≥75 years)
Comorbidities, particularly cardiac
Poor functional status and/or patient-reported minimal physical activity
Poor health-related quality of life
Low forced expiratory volume in one second (<30%)
Low body mass index (<20%)
One or more hospitalizations in the past year

Framework for providing primary palliative care:

Use a team: share responsibility for care with nurses, social workers, respiratory and physical therapists, chaplains and—if additional support and/or complex symptom management are required—experts in palliative medicine.
Screen for and address unmet needs in the management of symptoms such as breathlessness, depression and anxiety.
Conduct early and regular discussions about future care and concerns. “Would it help to talk about what to expect or what to prepare for as your illness worsens?”
Encourage advance care planning: Identify decision-makers and clarify any desired limits to potential interventions. “Are there treatments or interventions that you would not want as you approached the end of life?”

Source: “Palliative Care in COPD: An Unmet Area for Quality Improvement,” International Journal of Chronic Obstructive Pulmonary Disease; August 6, 2015; 10:1543-1551. Vermylen HJ, Szmuilowicz E, Kalhan R; Section of Palliative Medicine and Asthma and COPD Program, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago.

Complementary Therapies Increase Comfort, Well-Being of Hospice Patients

Mon, 17 Jul 2017 00:00:00 -0400

Studies suggest that complementary and alternative therapies (CAT) enhance quality of care for patients nearing the end of life. Some types of CAT are associated with a lessening of symptoms, including anxiety and pain, and improvements in mood and sense of control. Acupuncture and “gentle touch” therapies like massage, reiki and reflexology have been shown to reduce pain and nausea. Research also shows that music and pet therapies reduce stress and, for some patients with memory disorders, generate positive emotional responses.

A 2007 National Home and Hospice Care Survey (NHHCS) on the use of complementary and alternative therapies in hospice showed that such therapies may provide another avenue to address the hospice goal of improving quality of life at the end of life. The survey showed:

41.8% of hospice care providers offered CAT services, had a CAT provider on staff or under contract, or both
Among hospice care providers offering CAT:

72% offered massage
70% offered supportive group therapy
62% provided music therapy
59% used pet therapy
53% provided guided imagery or relaxation

VITAS provides complementary and alternative therapy services for our patients.

Common Complementary and Alternative Therapies

Acupuncture/Acupressure
Aromatherapy
Art therapy
Chiropractic and osteopathic manipulations
Deep breathing/Relaxation techniques
Massage therapy
Meditation
Music therapy
Pet therapy
Yoga/Pilates/Movement therapies

Key Findings

“Simple Touch” Therapies Ease Pain, Emotional Distress

A 2008 study in the Annals of Internal Medicine showed that advanced cancer patients in moderate to severe pain showed statistically significant improvements in pain relief, physical and emotional distress, and quality of life after 2 weeks of massage or simple touch therapy.
Massage, reiki and other therapeutic touch therapies have been found to have physiological and psychological effects, influencing neuroendocrine functioning and reducing stress and pain, and ultimately promoting comfort and well-being. American Journal of Hospice & Palliative Medicine^® 2015, Vol. 32(1) 90-100
A study analysis suggested that therapeutic massage over an extended end-of-life period offers enhanced benefit to terminally ill patients. American Journal of Hospice & Palliative Medicine^®Volume 26 Number 4 August/September 2009 246-253

Music Therapy Decreases Anxiety, Promotes Relaxation

In hospice care, music therapy is a powerful tool for physical, emotional and spiritual care. A 2005 study conducted by the music department at the State University of New York showed that music therapy can:

Decrease anxiety and pain
Promote relaxation
Facilitate communication
Provide support in life review and legacy work

Music therapists assess the strengths and needs of the patient and design a plan of treatment that includes singing, moving to and/or listening to live, patient-preferred music in individual, group and/or family sessions. Music therapy provides the most benefit to patients who:

Lack social interaction or sensory stimulation
Experience pain and symptoms that are difficult to control through traditional medical interventions
Feel anxious or are affected by dementia
Look for a concrete way to cope or to define or articulate feelings or thoughts
Face communication problems due to physical or intellectual impairments
Need spiritual support, possibly involving other family members
Enjoy music to enhance their quality of life or maintain dignity

Animal Therapy Provides Documented Health Benefits

Numerous scientific studies support the conventional wisdom that people derive health benefits from having pets. Owning a pet has been shown to improve cardiovascular health, reduce stress, decrease loneliness and depression, and facilitate social interactions among people.

Many studies also highlight the physical and emotional benefits of pet interaction for the ill and elderly. A 2014 survey analysis by a Pittsburgh cancer center indicated that therapy dog visits during chemotherapy reduced patients’ anxiety and depression. American Journal of Hospice & Palliative Medicine^® 2014, Vol. 31(4) 420-421

These effects are particularly noticeable in patients with dementia.

In A 2013 study in the Annals of Long Term Care, over a 10-week period of pet therapy, dementia patients:

Experienced a slowing in the progression of dementia-related symptoms, including agitation, aggression and depression
Had improved or less degraded verbal skills

A 2013 randomized controlled trial found that animal therapy may delay the progression of symptoms such as agitation, aggression, and depression in nursing home residents with dementia

Guidelines to Advance Care Planning

Mon, 16 Apr 2018 00:00:00 -0400

Are You Billing for EOL Discussions or Planning?

Voluntary advance care planning (ACP), which is reimbursed by the Centers for Medicare & Medicaid Services (CMS), enables certain clinicians¹to engage in conversations about preferences at the end of life with patients, family members and/or surrogates. Hospitals may also bill for ACP services. To successfully bill for ACP, a face-to-face discussion of short-term treatment options and/or long-term goals of care with the patient or healthcare surrogate is required.

Medicare Pays for ACP as either²

A separate Part-B service when medically necessary

An optional element of a beneficiary’s annual wellness visit

There are no limits on the number of times ACP can be reported for a given beneficiary in each time period. However, with each billing for the same patient, CMS expects to see a documented change in the beneficiary’s health status and/or wishes regarding end-of-life care.

Private insurance may cover the cost of the ACP discussion for non-Medicare patients. If not, physicians who have addressed ACP in a conversation about a serious illness can use “counseling and coordination of care” codes.

ACP has significantly improved multiple outcomes, particularly for patients with serious illness, including³:

Higher rates of completion of advance directives
Increased likelihood that clinician and family understand and comply with patient’s wishes
Reduced use of intensive treatments and hospitalizations at the end of life
Enrollment in hospice
Increased likelihood of dying in the preferred place¹

Use these CPT® codes to bill for ACP²

99497 Advance care planning, including the first 30 minutes of explanation and discussion (when performed) of advance directives such as standard forms. Reimbursement equates to 1.5 RVUs.

99498 Each additional 30 minutes; reimbursement equates to 1.4 RVUs.

Check that these reimbursement codes have been added to your billing system, as they may not be available until your facility approves them for use.

These ACP codes can be used on the same day as other CPT codes, as long as the other services were provided outside of the time window in which the ACP service was conducted.

Footnotes:

¹Only physicians, NPs and PAs can bill to these codes.

²Centers for Medicare & Medicaid Services, Fact Sheet: Advance Care Planning, August 2016 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network MLN/MLNProducts/Downloads/AdvanceCarePlanning.pdf

³Deterling, K. Advance care Planning and Advance Directives http://www.uptodate.com/contents/advance-care-planning-and-advance-directives#H37130455

CPT is a registered trademark of the American Medical Association.

What Does VITAS Do for Patients and Families Coping with Advanced Lung Disease?

Thu, 10 Oct 2024 00:00:00 -0400

Your patient with advanced lung disease is on multiple medications, prone to exacerbations, in and out of the hospital. Family caregivers are stressed, the patient needs increasing assistance with activities of daily living. The family calls your office, 9-1-1, and the hospital.

VITAS can help. We have the resources to keep your high-risk, hospice-eligible ALD patient at home and comfortable during a crisis, day or night, and relieve the cost burden to the patient and their insurer. Let’s talk about the VITAS services that can make a difference.

What Does VITAS Offer?

Medications

Proactive clinical approach that enhances quality of life and symptom management

Related medications are covered at no additional cost

Collaborate with PCP and/or pulmonologist on plan of care
Medications*: corticosteroids, mucolytics, antitussives, bronchodilators and other related medications
Antibiotics
IV fluids*/hyperdermaclysis*/other program-specific treatment modalities*
Home-based education regarding medication administration to maximize efficient delivery bronchodilators
Intensive management of dyspnea, anxiety and other symptoms

*Requires clinical case discussion between the VITAS medical director and attending physician.

HME/supplies

Provide necessary equipment for patient safety, quality of life and caregiver support
Financial burden of high costs is relieved
Nebulizers
BiPap, CPAP or other non-invasive ventilation
Oxygen, including high-flow
Wheelchair, shower chair, bedside commode—to help with energy conservation
Hospital bed, over-bed table
Mattress variations to reduce skin breakdown (including low-air-loss mattress)
Hoyer lift for safety of transfers, energy conservation & caregiver assistance
Diapers, barrier creams, gloves, wound care supplies

High-acuity levels of care

Telecare®: 365/7 and weekends. Live clinicians, triage, after-hours and emergency calls

Licensed clinicians have real-time access to the patient EMR to best support patient/family/facility through a respiratory crisis. If needed, the clinician will also dispatch a nurse to patient home.

After-hours clinicians: Designated nurses who respond to after-hours and emergency calls.
Intensive Comfort Care® (continuous care): When a change in condition or acute respiratory exacerbation requires intensive symptom management, VITAS is able to provide, on a temporary basis in the home, a licensed nurse and/or HHA at the patient’s bedside per Medicare guidelines.
General Inpatient Care: Intensive symptom management on a temporary basis when acute respiratory exacerbation or change in symptoms cannot be managed at home.

Complex modalities

Oxygen: Back-up O2 tanks for emergency power outages, high-flow and liquid oxygen with option for Venturi & non-rebreather mask
Ventilator removal support
Tracheostomy (non-ventilator-dependent)
BiPAP, CPAP or other non-invasive ventilation
Thoracentesis*
Pleurex drains
Respiratory therapist*
Dietician support
Therapy services*: PT, OT, speech

Only if appropriate and approved by VITAS medical director. May be program-specific. Check with your program.

Care team

Hospice Aide: Based on individualized plan of care: bathing, dressing, feeding, etc.
Nurse: Symptom management, medication review, disease-specific education
Physician: Collaborative support with PCP/pulmonologist
Volunteer: Life review, friendship, reading books, QOL activities
Respite care: For caregiver burnout/relief up to five days
Chaplain: Non-denominational support, discussions providing closure
Social Worker: Family meetings, counseling, facilitating reunions, access to community resources, help with emotional suppression
Respiratory Therapist: Pulmonary hygiene, teaching, support
Alternative Therapy: Massage, music, pet visits*
Patient/family educational resources that energy conservations techniques, meditation, depression, anxiety, oxygen safety, advance care planning

Originally published August 4, 2017 and updated October 9, 2024.

Wound Care in Hospice Settings

Thu, 21 Jan 2021 05:00:00 -0500

The goal of hospice is to promote quality of life with a focus on managing pain. The skin deterioration observed in pressure ulcers or other wounds is a symptom of body systems breaking down.

Even in the final stages of life, good wound care can contribute to physical, psychological and emotional comfort. Wounds can generate feelings of fear, aversion and suspicion of neglect. Poor wound care—or lack of wound care—can be devastating to the patient and family’s experience of death.

Pressure Ulcers in Hospice Patients

Pressure ulcers (bedsores) occur in more than 40 percent of hospice patients. Even with aggressive preventive measures, critically ill patients experience compromised healing response due to impacted muscle cell and immune function, among other factors. For these patients, pressure ulcer formation may be a visual biomarker that the critical illness has overwhelmed the body; skin breakdown is neither preventable nor treatable.

Family members of terminally ill patients may view pressure ulcer formation as a failure on the part of the healthcare staff caring for the patient—or even as their own failing, if they are responsible for providing care. Their emotional response may lead to requests that compromise the patient’s comfort-focused plan of care.

However, in general, prevention and treatment should not compromise the hospice philosophy of providing comfort care. Studies show that when patients are more comfortable in one position due to advanced illness, comfort should supersede preventive measures. If hospice staff deem that routine patient turnings contribute to increased pain, turnings may be suspended.

Other Wounds Common in Hospice

Due to the wide variety of patients and conditions treated in hospice care, you may encounter an equally wide variety of wound types:

Arterial insufficiency—Often appears as ulcers with black eschar on the lower leg and foot. The skin surrounding the wound appears to be very thin, shiny and usually hairless. The foot may feel cold and appear dusky red or pale.
Diabetic ulcers—Typically on the plantar surface of the foot and the second metatarsal head. They are usually painless.
Venous ulcers—Occur in the so-called gaiter area, halfway up the calf and down to just below the ankle. The skin likely feels itchy and appears mottled brown or has black staining and may appear crusty. The legs may become painful with sitting.
Tumors or fungating lesions—Occur most often in cancer of the breast, but may occur with other types of cancers, including head and neck, malignant melanomas and sarcomas. The lesion may be a small crusted area or a large ulcerated area with profuse exudate and capillary bleeding. They are often disfiguring, distressing and isolating. Odor and exudate management may be a particular problem in this type of wound.

Risk Factor Assessment and Prevention

Risk assessment upon admission is crucial and must include a full body check. Pressure ulcers are caused by intrinsic and extrinsic factors, including immobilization, cognitive deficit, inability to verbalize discomfort or numbness, chronic illness, aging and poor nutrition.

Once risk factors are established, preventing wounds from occurring is the best practice. Prevention measures include, but are not limited to, inspecting the skin and monitoring for proper moisture control. Proper positioning, transfer techniques and nutrition are essential for the comfort of the patient.

Avoid pressure on the heels and bony prominences of the body, and use positioning devices whenever feasible. As always, remember to document the condition of the skin after assessment.

Staging Wounds

The following wound stages are established by the National Pressure Advisory Panel:

Stage I—The skin is intact with non-blanchable redness of a localized area. Darkly pigmented skin may not have visible blanching, but its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Stage II—Look for partial-thickness loss of dermis presenting as a shiny or dry shallow open ulcer with a pink wound bed, without slough or bruising. It may also present as an intact or ruptured serum-filled blister. Stage II does not describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Stage III—Indicates full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of the tissue loss. There may be undermining and tunneling. The depth of a stage-III pressure ulcer varies by anatomical location.
Stage IV—Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. This wound often includes undermining and tunneling. The depth of a stage-IV pressure ulcer varies by location. Stage-IV ulcers can extend into muscle and/or supporting structures, making osteomyelitis possible.
Deep-Tissue Injury—A purple or maroon localized area of discolored intact skin, or a blood-filled blister due to damage of the underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Unstageable—Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

Basic Principles of Wound Care

The first step in determining a successful wound plan of care involves establishing the patient’s prognosis, condition and potential for wound healing. For instance, a less aggressive approach will be necessary for someone in the final days of life, or when it is evident that healing is not realistic.

It’s important to set appropriate goals based on the prognosis, condition and potential for healing. Goals for hospice patients may include:

Preventing complications of the wound, such as infection or odor
Preventing additional breakdown of the skin
Minimizing harmful effects of the wound on the patient’s overall condition

When developing a care plan for a patient, it is important to factor in their status and desires. Interventions should be re-evaluated every two weeks to determine whether the plan is still appropriate. A wound’s failure to heal does not necessarily imply that other measures are more appropriate, or that all possible approaches should be attempted. Instead, focus on developing the best option for the patient based on their present condition and their desires.

A basic wound care plan will incorporate these elements:

Cleansing debris from the wound
Possible debridement
Absorbing excess exudate
Promoting healing
Treating infection
Minimizing discomfort

In hospice care, the pain, appearance, odor and perceived implications of wounds can be incredibly distressful for the patient and family. To stay in alignment with hospice’s mission of comfort care, the entire hospice team must operate with vigilance, assessing and documenting wounds and condition changes in detail, maintaining proper preventive measures and developing plans of care that consider the patient’s needs and desires.

By reducing the occurrence and severity of wounds and mitigating their effects, the hospice team contributes to quality of life and facilitates a peaceful death experience for both patient and family.

Palliative Care Improves Quality of Life, Well-Being for Advanced Heart Failure Patients

Mon, 13 Nov 2017 00:00:00 -0500

Patients with advanced heart failure (HF) who receive ongoing, coordinated palliative care in the outpatient setting following hospital discharge show significantly greater improvement in quality of life, spiritual well-being and symptoms of depression and anxiety compared with patients receiving usual cardiology care only, according to a report of the results of a rare, randomized trial published in the Journal of the American College of Cardiology.

“HF progression is a frightening and uncomfortable experience for patients, with both physical and psychological sequelae,” write the authors. “The addition of palliative care principles in this vulnerable population improved physical, psychosocial (anxiety/depression) and spiritual quality-of-life measures—the key domains of patient experience in serious illness.”

6-Month Palliative Intervention

Investigators analyzed results of a trial in which 150 patients with advanced HF who were at high risk for rehospitalization and six-month mortality (mean age 71 years; female 47%; black race 41%) were randomized to usual care (UC), i.e., evidence based HF management, or usual care plus a palliative care intervention (UC + PAL). The interdisciplinary palliative care intervention, the Palliative Care in Heart Failure (PAL-HF) trial, enrolled patients between August 2012 and June 2015. The intervention phase of the trial was six months, but patients were supported afterward via contact every three months until death or the study’s end.

Palliative was coordinated by a certified palliative care nurse practitioner in conjunction with a physician specialist in hospice and palliative medicine. Each patient’s clinical cardiology team collaborated in the shared goal setting of combining HF symptom control with palliative care.

HF and General Quality of Life

Quality of life was assessed using two measurements, one for HF-specific quality of life and the other for general and palliative-care-specific quality of life.

The Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary is scored from 0-100. Higher scores represent better health; a 5-point change is considered clinically meaningful.
The Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal) is self-reported quality-of-life assessment with a range of 0-184. Higher scores indicate better quality of life; a 10-point change is considered clinically meaningful.

Assessments of depression, anxiety and spiritual well-being were measured using the Hospital Anxiety and Depression Scale (HADS) and the FACIT-Spiritual Well-Being scale (FACIT-Sp).

HADS has a range of 0-42, with depression and anxiety subscores ranging from 0-21. Higher scores indicate worse symptoms.
FACIT-Sp scores range from 0-48. Higher scores indicate more spirituality.

Benefits Observed after 3 Months

Patients in the UC + PAL group had greater improvement in all endpoint scores at six months than did those in the UC-only group, with the real benefit of the palliative care intervention becoming observable after three months. “We posit that this finding may be related to the sustained involvement of palliative care and the relationships that develop between patients, their families and care teams,” the authors suggest.

Mean differences in assessment scores at six months, UC + PAL vs UC-only:

KCCQ (HF-specific) difference, 9.49 points; 95% confidence interval (CI), 0.94 to 18.05; P = 0.03
FACIT-Pal (palliative-care-specific) difference, 11.77 points; 95% CI, 0.84 to 22.71; P = 0.035
HADS-depression difference, -1.94 points; 95% CI, 3.57 to -0.31; P = 0.02
HADS-anxiety difference, -1.83 points; 95% CI, -3.64 to -0.02; P = 0.48
FACIT-Sp (spiritual) difference, 3.98 points; 95% CI, 0.46 to 7.50; P = 0.027

Care That Reaches Beyond the Health System

“The findings support the patient-reported benefits of a care delivery model that transitions and changes, much like symptoms do, beyond the walls of the health system to the community and home settings,” write the authors. “PAL-HF is the first randomized, controlled trial of a longitudinal palliative care intervention to show the significant clinical benefit of embedding such an interdisciplinary intervention in the overall management of patients with advanced HF.”

The authors suggest that larger, multicenter studies are needed to confirm the results of their study, which is limited by being a single-center trial. Study strengths include the “diverse and high-risk HF cohort that mirrors the broader population commonly admitted to the hospital,” they note.

The quality-of-life outcomes were derived from patient reports rather than “hard endpoints,” which are often of less importance to patients. “Many of these patients have a strong desire for relief of suffering and assistance with end-of-life planning,” note the authors. “PAL-HF provides empirical evidence that palliative care improves health-related quality of life in end-stage HF patients.”

Source: “Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial,” Journal of the American College of Cardiology; July 18, 2017; 70(3):331-341. Rogers JG, Patel CB, Tulsky JA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute; and Division of Palliative Medicine, Department of Medicine, Brigham and Women’s Hospital, both in Boston.

Performance Status Alone Found Effective Tool for Prognostication in Advanced Cancer

Tue, 21 Feb 2017 00:00:00 -0500

Predictive Ability

A simple prognostic model based on performance status has predictive ability that is similar to more complex models in patients with advanced cancer, and can thus be a useful prognostic tool for busy clinicians in outpatient settings, according to a report published in the Journal of Oncology Practice, a journal of the American Society of Clinical Oncology.

“In our study, we found that performance status alone ... was effective in delineating the survival of outpatients with advanced cancer, as seen by the Kaplan-Meier survival curves and the highly significant log-rank test for trend,” write the authors, led by Raymond Jang, MD, MSc, a medical oncologist at the Princess Margaret Cancer Centre within the University Health Network, a research hospital affiliated with the University of Toronto.

“As for any model, this estimate requires adjustment by the clinician, based on clinical impression and experience,” add the authors. “However, unlike for other models, there is no need to collect and enter other clinical or laboratory information into an algorithm.”

A Simpler Model

Various models have been developed to assist clinicians in assessing survival, but because they incorporate multiple variables related to prognosis, they are often complex, requiring input of laboratory values or conversion calculations that are “time consuming and impractical for rapid outpatient assessment,” note the authors. In addition, these more complicated models are often designed to determine shorter survival probability for use in patients closer to death.

“Our findings best apply to ambulatory patients with advanced cancer whose clinical prognosis is a year or less,” the authors point out. “However, this is also the population for which prognostication is the most uncertain and of greatest importance, particularly in terms of end-of-life planning.”

Performance status, or assessment of the patient’s level of function, is already routinely employed in oncology outpatient settings, note the authors. The most commonly used model is the Eastern Cooperative Oncology Group (ECOG) scale, followed in popularity by the Karnofsky Performance Status (KPS) scale. In palliative care settings, the Palliative Performance Scale (PPS), which is based on the KPS, tends to be the most utilized tool.

“Although these three measures are known to be correlated with survival, there has been no study (to our knowledge) assessing and comparing their predictive validity in relation to actual survival time,” observe the authors.

Investigators compared actual survival with survival estimates based on three performance status scales completed by physicians for each of their adult patients with cancer (n = 1655; median age, 65 years; female, 51%) newly attending an outpatient oncology palliative care clinic in Toronto between 2007 and 2010. At the time of analysis, 91% of patients had died. Overall, median survival for all patients was 135 days (95% confidence interval [CI], 123 to 144 days).

Key Findings

C-statistic, which measures predictive ability, was 0.64 for the ECOG model—indicating modest predictive performance—and 0.63 for the PPS and KPS models.
Similarly, the C-statistic for the more complex PiPS-A and PiPS-B (Prognosis in Palliative Care Study) models, which use 10 to 12 variables and require blood work, was between 0.67 and 0.69.

“Performance scores delineated survival well using any of the performance measures,” note the authors, and “the ECOG, PPS, and KPS all have similar predictive ability.” Study physicians completed the ECOG, KPS and PPS for each of their respective patients at the end of the initial consultation. Separate survival analyses were performed for the scales, using the Kaplan-Meier method.

The study also provided survival estimates for each performance level. For the ECOG, for example, the estimated survival for each improved performance level was approximately twice that of the performance level below it. A similar pattern was also found for KPS and PPS. For the ECOG measure (scored from 0 [normal activity] to 5 [death]), median survival was:

293 days (95% CI, 242 to 403) days for patients with a score of ECOG 0
197 days (95% CI, 183 to 219 days) for ECOG 1
104 days (95% CI, 90 to 118 days) for ECOG 2
55 days (95% CI, 46 to 66 days) for ECOG 3
25.5 days (95% CI, 17 to 51 days) for ECOG 4

“A clinician need only remember that an ECOG of 4 corresponds to a median survival of approximately 25 days in order to easily calculate the median survivals for the other ECOG levels,” suggest the authors. “Survival was approximately halved for each worsening performance level.”

Patients with advanced cancer and their family members often ask questions related to prognosis, and although clinical prognostication can be difficult, “open, empathic discussions about this topic may improve satisfaction with care,” note the authors, who hope use of this simple tool can enable more proactive advance care planning.

“Accurate prognostic information can help physicians decide whether to initiate or continue anticancer therapy, facilitate transitions to hospice care, and enable appropriate advance care planning and end-of-life decision making.”

Source: “Simple Prognostic Model for Patients with Advanced Cancer Based on Performance Status,” Journal of Oncology Practice; September 2014; 10(5):e335-341. Jang RW, Caraiscos VB, Swami N, Banerjee S, Mak E, Kava E, Rodin G, Bryson J, Ridley JZ, Le LW, Zimmermann C; University of Toronto and Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.

Why Partner with a Hospice Provider?

Wed, 19 Jun 2019 00:00:00 -0400

Updated 06/19/2019

VITAS Healthcare is the largest provider of hospice care in the U.S. and a pioneer in the industry. Partner with us to ensure your patients experience dignity and respect as they near the end of life.

Partnering with VITAS: Good for your patients. Good for your organization.

Hospice services make families feel better. They allow terminally ill patients to enjoy a better quality of life. And a hospice provider like VITAS Healthcare can assist in satisfaction scores along with margin improvements for its partner hospitals, healthcare systems and health plans.

Interdisciplinary teams of hospice experts, from nurses to chaplains to physicians, bring VITAS services to wherever our patients call homes. We provide round-the-clock staffing when medically necessary to keep patients comfortable at home. And we provide inpatient care when home care isn’t enough.

When we work as your partner, VITAS leverages our technology, staff and experience to transition complex patients with multi-comorbidities from hospital to wherever they call home. Then we provide the support necessary to improve quality of life, manage symptoms and prevent readmissions.

Through our care continuum, VITAS supports the Institute for Healthcare Improvement’s “triple aim”: improve patient care, reduce per-capita costs, support the health of the population. We also improve the clinician experience, vital if we’re going to meet CMS goals.

Want to talk about partnering with VITAS? Call 800.873.5198

Our innovative interoperability solution automates hospice referrals from your ED. At no cost to you, VITAS accelerates and simplifies the hospice admission process, freeing your staff and resources for other tasks. And our response time assists in your throughput and boarding challenges, thereby improving your ED inpatient and outpatient core measures.

We’re Here to Help Our Healthcare Partners

VITAS recognizes the problems:

Mitigate risk
Improve longitudinal patient-centered care through the care continuum
Reduce overspending and duplication of effort
Work smarter
Collaborate to successfully navigate the new healthcare landscape

And VITAS is part of the solution. We offer:

A care transition pathway that breaks the discharge/home/ED/readmission cycle and moves patients to appropriate non-acute settings
An interoperability framework that interfaces with our partners’ EMR systems to streamline referrals and care transitions
Mobile apps that help clinicians make referrals and stay connected to us
An iPad transition-to-care platform that improves the admissions experience for patients, families and healthcare professionals
A fleet of trucks that delivers VITAS medical equipment to patients’ homes
24/7 virtual care centers staffed by VITAS clinicians who can answer questions and dispatch a member of the hospice team to any patient at any time of the day or night
VITAS-authored texts on end-of-life care
VITAS-sponsored palliative care fellowships with several of the country’s best medical schools
A charitable foundation that passes every dollar of every donation to needy hospice families and like-minded charities

VITAS Healthcare has been improving hospice services since 1978. Today we care for more than 18,000 terminally ill patients every day.

Join us. Together we can chart new paths in the ever-changing healthcare landscape that alter the way we live—and die.

The Hospice Transition: How Medications Change

Wed, 01 Nov 2017 00:00:00 -0400

The transition of a patient from curative care to palliative or hospice care brings changes in treatment philosophy. One of those involves medications.

A terminally ill patient has likely been taking an ever-increasing quantity of life-extending drugs, perhaps for years. It is part of the progression of the disease. With the transition to hospice, those drugs must be re-evaluated along with the patient’s and family’s goals of care.

Hospice Meds Address Symptoms, Not the Disease

Hospice physicians use meds in a different way, addressing symptoms, not the disease process. As such, they are very comfortable using relief medications—like morphine—more aggressively than a referring physician would.

Just as the referral physician adjusts the meds as the patient’s condition progresses, the hospice doc adjusts meds as well, but in the opposite direction. As death approaches, the patient’s metabolism changes; the need for medication naturally reduces.

As VITAS Healthcare Regional Medical Director James Wright, DO, says, “The difference is in scope and objective: medications can’t and shouldn’t remain the same.”

Reassuring Patients About a Change in Meds

Reduced meds can be a cause for concern for a hospice patient. The administration of fewer and milder drugs requires more communication, specifically on the part of the referring physician, who presumably has been caring for the patient for a significant duration of the illness.

Hospice physicians are available to consult with a referring physician who wants to follow their patient through the hospice transition. But because hospice happens in the home, many referring physicians turn day-to-day care over to the hospice team rather than add house calls to an already over-scheduled day.

Patients seeing a new physician and learning of a change in medications worry that their physician is “giving up” on them or that they are no longer worthy of intensive care. They need to be reassured that neither is true.

In fact, transitioning to hospice means transitioning away from clinically demanding and expensive medications. The results are simpler for the patient, with less symptom burden, fewer side-effects, more comfort and more dignity.

Emergency Physicians Uniquely Placed to Assess Patients’ Hospice and Palliative Care Needs

Thu, 24 Aug 2017 00:00:00 -0400

“Most patients’ palliative needs can and must be addressed by medicine’s frontline providers: Emergency physicians.” —David H. Wang, MD, Annals of Emergency Medicine

Because physicians in emergency departments (EDs) frequently encounter patients with life-limiting illness who present with challenging complaints, they have the opportunity to recognize what may be overlooked in routine office visits—that a patient would benefit from palliative/hospice care, according to an article published in Annals of Emergency Medicine, the official publication of the American College of Emergency Physicians (ACEP).

“The ED has a unique opportunity to serve as a hub for unmet palliative care needs,” writes David H. Wang, MD, an emergency medicine and palliative care physician practicing in the San Francisco area. In the article, Wang offers emergency physicians quick and practical tools for assessing needs and implementing palliative care in the ED.

Early palliative care has been shown to reduce ED visits and hospitalizations by as much as 50% across settings and disease populations, points out Wang. Palliative care—of which hospice and comfort care are components—is “a win-win for patients and for healthcare systems,” he writes. “Rather than being ‘another thing for emergency physicians to do,’ intervening early for these patients has a palpable effect on lives.”

While the percentage of US hospitals with palliative care programs has been increasing in recent years, the number of specialists in palliative medicine is not sufficient to meet patient needs, notes Wang. Thus, “Most patients’ palliative needs can and must be addressed by medicine’s frontline providers. Emergency physicians must now develop ‘primary palliative care’ expertise unique to their practice climate.”

Components of a Palliative Care Assessment

Prognosis. “Although comprehensive screening tools are being developed and validated, perhaps the single easiest and most predictive tool remains the question, ‘Would I be surprised if this patient dies in the next 12 months?’” writes Wang. Although not yet validated in the ED setting, this tool has potential to be actionable in a time-limited setting, he notes.

Goals of care. Keeping in mind the time constraints and competing distractions of a busy ED, Wang provides a simple, five-minute framework for holding a goals-of-care discussion. This “crucial discussion” is as much about acquiring a sense of the patient’s/family’s emotional drivers as it is about information exchange, notes Wang, explaining that “families are better equipped to collaborate around ‘goals’ rather than specific interventions.”

Five-minute goals-of-care discussion in the ED

Minutes 1–2:

Elicit patient understanding of underlying illness and today’s acute change.
If available, build on previous advance directives or documented conversations.
Acquire sense of the patient’s values and character, to help frame prognosis and priorities for intervention.
Name and validate observed goals, hopes, fears and expectations.

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 prognosis is dire.

Minute 5:

Summarize and discuss next steps.
Introduce ancillary ED resources (e.g., hospice, observation, social work, chaplain).

Suggested supportive phrasing

Physicians can help families/surrogates understand options and make care choices by being aware of the importance of word choice and intentionally selecting alternatives to commonly used phrases, Wang suggests. “Given the significant information asymmetry between providers and patients, word choice is critical when options are being presented.”

Instead of “Do you want us to do everything possible?” physicians can ask, “What is most important to [name] right now?”
Instead of “Would [name] want heroic measures?” physicians can ask, “What was [name] like before the illness?”
Instead of “I wouldn’t want this for my mother,” physicians can say, “Tell me about your mother.”
Instead of “Do you want us to push on your mother’s chest, use electricity, and provide her with a breathing machine?” physicians can ask, “Based on what you’ve told me about her, do you think she would want to die a natural death?”
Instead of “There is nothing more we can do,” physicians can say, “We will aggressively make [name] comfortable.”

Options for disposition from ED to palliative/hospice care include:

Early outpatient palliative care referral
Inpatient palliative care consult
Direct ED-to-hospice discharge
Discharge to inpatient hospice bed, if available, for patients whose symptoms cannot be adequately controlled at home
Short-stay private room for imminently dying comfort-care patients

“Palliative care begins in the ED and bridges into inpatient and outpatient services,” concludes Wang. “Current momentum hinges on greater education and research. Historically, emergency physicians have prided themselves on being first-movers. Now is the time to own the change.”

Social Workers Play Critical Role in Hospice & Palliative Care

Mon, 05 Mar 2018 00:00:00 -0500

March is Social Work Month

Social workers and case managers charged with placing patients into appropriate care settings often turn to hospice providers. They know that hospice services can help when a patient is not responding to curative care as hoped, when hospitalization is no longer the answer, or when the patient refuses painful and/or futile therapies.

But what does the social worker on the hospice team do? Just like hospice doctors and nurses who handle the unique and challenging issues that arise at the end of life, social workers are also key members of a patient’s hospice team.

VITAS social workers, in fact, are front-line healthcare professionals, serving as the eyes, ears, sounding board and confidantes of their patients and families. They provide guidance, resources and direct intervention when end-of-life symptoms, circumstances and diagnoses arise or change.

March is National Social Work Month, an ideal time to examine the social worker’s role in the hospice and palliative care specialties. Licensed clinical social workers are employed throughout the healthcare profession, and they can take advantage of special training in partnership with the National Hospice and Palliative Care Organization to earn special certification as a hospice and palliative care social worker.

Social Workers: Champions for Compassionate End-of-Life Care

Social workers function as patient advocates on a hospice interdisciplinary team. They spend time with patients and families to understand underlying emotional and psychosocial dynamics and needs. They also make sure that other members of the team—doctor, nurse, chaplain, bereavement specialist and volunteer—keep the patient’s and family’s end-of-life preferences and wishes in mind in support of clinically sound, patient-centered care.

And when conventional treatments are no longer effective or curative, hospice social workers help patients and healthcare professionals navigate the emotional, psychosocial and related clinical issues that arise from a life-limiting diagnosis.

Hospice social workers:

Understand the range of medical conditions for which hospice care is appropriate, including cancer, heart disease, Alzheimer’s/dementia, lung disease, liver and kidney failure, HIV/AIDS, ALS and other neurological diseases, trauma and more.
Can help physicians and nurse practitioners determine when terminally ill patients are eligible for hospice care.
Can help inform decisions about the most appropriate setting—home, hospital, skilled nursing facility, assisted living center or inpatient unit—for a patient’s hospice care, depending on the diagnosis and prognosis.
Can identify local hospice providers and community resources that are available to patients and families.
Address the unique needs of special patient populations at the end of life, depending on culture, beliefs, values and life experiences. Special patient populations at VITAS include military veterans; patients who identify as LGBTQ; Jewish, African American, Latino, Haitian or Asian patients; patients who speak a language other than English, and patients whose personal beliefs and preferences are shaped by their cultures or religions.
Monitor care plans closely with the hospice team to make sure that care responds in real time to a patient’s condition, worsening/improving symptoms, caregiver capabilities and family dynamics.
Serve as the emotional hub for meeting patient and family needs. How are the patient, the family and the hospice team coping? What are the current patient and family dynamics? What has changed for the better? What has changed for the worse? Who needs help?
Handle many of the periphery details linked to a terminal diagnosis, including benefits and insurance forms, veteran’s issues, healthcare navigation, identification of and referrals to community resources (e.g., homemaking services, Meals on Wheels, food assistance), clergy communication, funeral arrangements, memorial services, family travel and more.

Facilitators for End-of-Life Conversations

A sensitive topic that hospice social workers face with patients and families is the end-of-life conversation, including advance directives and living wills. They often help patients and families talk about, document and agree to goals of care shaped by their wishes and preferences for end-of-life care—conversations that may be impeded by conflicting opinions or diverging values among patients and families about the best course of action.

Based on an early initiative from the VITAS San Antonio program, social workers are undergoing specialized training and certification as facilitators of advance care planning discussions. They work as a conduit between physicians, patients and families to ensure that frank and honest discussions are held about sensitive but necessary topics, from do-not-resuscitate orders, feeding tubes and medications to decisions about burial vs. cremation, or religious funeral vs. non-religious memorial service.

National Social Work Month is the ideal time to recognize the multiple roles, responsibilities and duties that social workers carry out for hospice patients, families and healthcare professionals.

Advanced Disease Management: Helping Patients Cope with Serious Illness

Tue, 24 Oct 2017 00:00:00 -0400

Meeting the demands of both healthcare reform and patients and their physicians, advanced disease management (ADM) programs are a patient-centered tool, like palliative care, that addresses serious illness from the perspective of intensive comfort care. They are typically run by physician groups and healthcare systems.

A nurse practitioner often leads the ADM team, partnering with the patient’s PCP or specialist physician. Other team members can include a physician, pharmacist, social worker, dietician, spiritual care counselor and/or therapists, as needed. Together they:

Address pain and symptom management
Educate the patient and family about the trajectory of the illness and what to expect
Help the family talk about complex medical decisions that must be made and how treatments will affect everyone’s quality of life

Like palliative care, ADM bridges the gap between curative care and hospice. The goal is to save money for insurers, including Medicare, while providing appropriate care for patients with serious progressive illness. According to a recent study in Health Affairs, medical costs in the last year of life are $80,000 per patient in the US, with more than 44% of those costs spent in hospitals.¹

How Advanced Disease Management Helps Patients and Families

ADM keeps patients out of the ED, ICU, skilled nursing facility, etc. It supports physicians by serving as a “first responder” to patients and families with fear, anxiety and questions who may demand frequent attention. And it communicates with patients about advance care planning and end-of-life care, topics research shows are not handled consistently or well by most physicians.²

Like palliative care, ADM is covered to some extent by some insurers—home visits, for example, may not be included. Services not covered by insurance can be paid for by the patient. ADM is appropriate at any stage of the patient’s disease and can be received along with curative treatment. ADM serves as a gateway, easing patients and families into home hospice services—sometimes earlier than would otherwise happen.

Advanced disease management is another device developed to achieve the Triple Aim, and to address end-of-life care appropriately. It is early initiation of palliative measures and intensive comfort care begun when there is still time to improve the quality of life for a seriously ill patient.

¹http://content.healthaffairs.org/content/36/7/121

²https://www.johnahartford.org/blog/view/talking-with-patients-about-end-of-life-care-new-poll-reveals-how-physician

Pediatric Palliative Care: a Gentle, Individualized Philosophy of Care

Fri, 05 Oct 2018 00:00:00 -0400

Child-Centered Solutions for Seriously Ill Children

Healthcare providers who care for children with chronic, complex or potentially life-limiting diseases and conditions can find additional, supportive solutions from experts in pediatric palliative care.

Palliative care’s goal is to relieve suffering and enhance quality of life for a child and family facing a serious, life-altering diagnosis. Interdisciplinary palliative care teams work closely with the patient, family and healthcare professionals—pediatricians, hospitalists, specialists, consultants and other members of the treatment team—to address pain, manage symptoms and provide compassionate, realistic, child-centered care at every phase of an infant’s, child’s or teenager’s illness or disease.

A Focus on the Person, Not the Disease

“We believe that every patient is a bio-psychosocial-spiritual being, and that’s how we base our approach to pediatric palliative care. We treat the person, not the disease,” says Amy Pantaleo, a VITAS nurse practitioner (NP) who works on the pediatric palliative care team at Joe DiMaggio Children’s Hospital in Hollywood, Florida. The team includes two physicians, two NPs, social worker, chaplain, music therapist, art therapist, child life therapist, exercise physiologist and yoga therapist to enhance quality of life for children, who may or may not be terminally ill.

The differences between palliative care for adults and children hinge on realistic expectations and the range of supportive services, Pantaleo explains. Pediatric palliative care starts at the time of diagnosis, positioning the palliative team as an extra layer of support throughout the patient’s and family’s journey.

“The adult world often focuses on aggressive, disease-directed treatment,” she says. “The pediatric philosophy is a lot gentler, more individualized. There’s more focus on treatments being done for a patient vs. being done to a patient, especially if a prognosis is deemed unfavorable.”

Here's what VITAS Nurse Practitioner Amy Pantaleo has learned:

“Children teach me that life is precious, and that life is not predictable,” she says. “They really do embrace every single day, especially children who are hospitalized for extended periods.

“They appreciate a smile, company or an unexpected visitor. They want to feel special, even if they feel very different or not very special at all. To me, they are all special because they are incredibly strong. They portray what it means to be a fighter.

“They teach me that there are so many different arrays of patients, people and families—some of them incredibly supportive and some not at all,” she says. “They teach me that no matter what their circumstances, I can give these children joy, something that touches their hearts.”

Here’s how pediatric palliative care supports healthcare professionals:

Goals-of-Care conversations:

The team coordinates care and helps parents, families and healthcare teams explore options and make difficult but informed decisions about ongoing treatments and supportive care, based on key questions:

What are your goals? What are your wishes?
What are your hopes and fears?
What kinds of family-centered, culturally appropriate and easily accessible care will help your child and your family most?
What interventions and treatments do you want to pursue or decline if your child’s disease progresses or worsens?
What are your preferences for end-of-life care?

Supportive therapies and integrative solutions:

Music, art and play therapy, relaxation, yoga, exercise, massage and other services help children cope with the stresses of hospitalization, treatments, symptoms and pain.

Consultation:

Palliative specialists educate medical teams about palliative options and are available to prepare physicians for family consultations about a child’s next phases of care (e.g., the risks-benefits of another major heart surgery) or pending decisions (e.g., whether to continue or stop chemotherapy or mechanical ventilation).

Family and sibling support:

Palliative specialists educate parents about an ill child’s diagnosis, prognosis and needs, and they also provide sibling counseling and ongoing bereavement support.

Who is Eligible for Pediatric Palliative Care?

Infants, children and teens who are referred to palliative services face challenging symptoms and diagnoses ranging from advanced cancer to HIV, cystic fibrosis to cerebral palsy, metabolic disorders to muscular dystrophy.

According to the National Hospice and Palliative Care Organization, key diagnoses for children receiving palliative care are:

41%: Anomalies linked to congenital or genetic defects/disorders
39%: Neuromuscular disorders
20%: Cancer

Longer Survival, Lower Costs, Less Likelihood of Hospital Death Linked to Heart Failure Patients under Hospice Care

Wed, 14 Nov 2018 00:00:00 -0500

Older adults with advanced heart failure (HF) and two or more hospital discharges within the previous six months who enrolled in hospice experienced not only lower use of acute healthcare than those receiving usual care, but also longer median survival and a lower likelihood of hospital death, according to a report published in JACC: Heart Failure.

“These observations support several other studies demonstrating that patients who enroll in hospice experienced a longer survival, and that hospice enrollment reduced healthcare use and costs,” write the authors. There is an estimated average cost saving of $2,300 per Medicare beneficiary enrolled in hospice, they point out, yielding an overall savings of more than $3.5 billion per year.

Hospice Addresses the Needs of Patients with Heart Failure

Heart failure is a leading cause of death in the US, and about 80% of those hospitalized with HF are over 65 years of age, note the authors. Further, up to 44% of older adults admitted to hospitals with advanced HF are readmitted within six months of discharge.

“Hospice is a model of care that could address the needs of patients with advanced HF and their caregivers,” write the authors. “Although the use of hospice by patients with HF has almost doubled in the past decade, the proportion of HF decedents who use hospice remains lower than that of other major diseases. Cardiovascular professional societies have called for the increased and earlier integration of hospice care for patients with advanced heart disease.”

How Researchers Examined the Data

Investigators analyzed data on a subsample of individuals from a longitudinal observational study of patterns of care among HF patients, identifying a cohort of individuals who had two or more HF hospitalizations (i.e., were admitted with a principal diagnosis of HF) within a six-month period during 2009 and died within six months of the second hospital discharge (unmatched sample, n = 7810).

Multiple hospitalizations for HF within a six-month period have been found to be a marker of increased disease severity and risk of death, note the authors.

Using Medicare and patient assessment data gathered by home care clinicians for the Outcome and Assessment Information Set (OASIS) in 2009, with follow-up data gathered in 2010, the researchers examined predictors of hospice enrollment among two propensity score-matched samples of 3067 persons each: those who enrolled in hospice and those who received usual care (mean age, 82 years; female, 53%; non-white, 15%).

Key Findings: Hospice Patients

Those enrolled in hospice had longer median survival compared with usual care patients (80 days vs 71 days; P = 0.004).
HF patients enrolled in hospice were less likely than those who received usual care to die in the hospital (3% vs 56%; P < 0.001) and less likely to die in a skilled nursing facility (1.0% vs 10%; P < 0.001).
Among enrollees, 57% died with home hospice, 32% died in inpatient hospice and 4% died under hospice care in an unknown setting.
The median number of days from the second discharge to hospice enrollment was 51 days (SD = 47 days); 33.3% of patients enrolled within 30 days after the second HF discharge and 8.1% enrolled within seven days after the second HF discharge.
Nearly one-half (45%) died within seven days of hospice enrollment.

Predictors of Hospice Enrollment

Those who enrolled in hospice were more likely than those receiving usual care to:

Be older than 85 years (45% vs 34%; P < 0.001)
Be white (86% vs 78%; P < 0.001)
Have a higher median household income ($53,193 vs $50,761; P < 0.001)
Be sicker (metastatic cancer, 9% vs 6%; P < 0.001)
Have dementia (22% vs 18%; P < 0.001),
Have dyspnea at rest or with minimal exertion (49% vs 44%; P < 0.001)
Have more functional dependencies (4.1 vs 3.8; P < 0.001)

“Although those who enrolled in hospice after the second HF hospital discharge were older, more likely to be white, and less likely to have Medicaid and disability entitlement than those who received usual care, these trends are similar to national statistics about hospice enrollment across all diagnoses,” the authors write.

In the six months prior to the second HF hospitalization, subsequent hospice enrollees had:

Fewer ED visits (3.1 vs 4.6; P < 0.001) than those who did not later enroll in hospice
Fewer all-cause inpatient admissions (1.70 vs 1.88; P < 0.001)
Fewer all-cause inpatient days (12.4 vs 14.0; P < 0.001)

There were no significant differences between the two groups for ICU days and SNF days in the six months before the second discharge. After propensity score analysis, only the mean number of ED visits remained a significant predictor of hospice use (2.38 vs 2.59; P = 0.01).

Propensity Score-Matched and Adjusted Findings

Within 30 days after the second HF discharge, those who enrolled in hospice had fewer ED visits (2.64 vs 2.82; P = 0.04) and spent fewer mean days in the hospital (3.90 vs 4.67; P < 0.001) and in the ICU (1.25 vs 1.51; P < 0.001) than did those not in hospice.

In the six months after the second HF discharge/hospitalization, those who enrolled in hospice had significantly fewer:

ED visits (4.25 vs 5.25; P < 0.001)
Inpatient stays (1.75 vs 2.18; P < 0.001) and inpatient days (11.7 vs 14.8; P < 0.001)
ICU days (3.75 vs 4.86; P = 0.04)
Skilled nursing facility stays (4.38 vs 6.44; P = 0.04)

Source:

“Predictors of Hospice Enrollment for Patients with Advanced Heart Failure and Effects on Health Care Use,” Journal of the American College of Cardiology: Heart Failure; September 2018; 6(9):780-789. Gelfman LP et al; Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York City; Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY; Center for Home Care Policy and Research, Visiting Nurse Service of New York, New York City; Independent Contractor, Bonny Doon, CA; and Divisions of Cardiology and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York City.

Antipsychotics and Your Terminally Ill Nursing Home Resident

Fri, 03 Mar 2017 00:00:00 -0500

The inclusion of the antipsychotic measure in the calculation of the Five-Star Quality Rating System for a nursing home has increased the scrutiny regarding administration of antipsychotic drugs. The goal of VITAS® Healthcare is to optimize symptom management; we prescribe antipsychotic treatment only when clinically substantiated. If antipsychotics are initiated for a specific symptom and the treatment is not effective, the treatment is discontinued.

Indications for Antipsychotics

Antipsychotics represent a key therapeutic medication class to help manage distressing symptoms in patients with advanced illness. Symptoms that may warrant and benefit from a trial of antipsychotics include perceptual disturbances (hallucinations, paranoia and delusions), nausea and vomiting, delirium and behavioral disturbances (agitation and terminal restlessness). Agitation and terminal restlessness are particularly common near the end of life, with prevalence rates reported more than 50% and 80% of the time, respectively.

Multidisciplinary Evaluation of Agitation and Terminal Restlessness

Agitation and terminal restlessness benefit from a multidisciplinary assessment that identifies potential contributors to the symptom burden. Such contributors should be assessed and managed in light of goals of care and life expectancy to promote patient-centered care. A thoughtful approach is displayed in the table below.

Non-Pharmacologic Management

In patient-centered care, non-pharmacologic approaches are incorporated as part of the care plan, along with considerations for pharmacologic treatment. Examples of non-pharmacologic techniques include sensory interventions (music or touch), care mapping (the social world that surrounds a person impacts well-being) and communication skills training. But non-pharmacologic techniques may be substantially less beneficial for people near the end of life.

That is, those most likely to respond to non-pharmacologic interventions tend to have higher levels of cognition, greater ADL independence, the ability to effectively communicate, the ability to speak and responsiveness. People less likely to respond to behavioral interventions tend to have physical symptoms, such as pain. The presence of agitation and terminal restlessness should include non-pharmacologic interventions, particularly music and touch, with the recognition that such treatments do not obviate the use of antipsychotics if deemed appropriate by the interdisciplinary team.

Pharmacologic Management

Antipsychotic use is reserved for patients who exhibit significant distress and/or endanger themselves, other patients or a caregiver. While no medication is FDA approved for the management of agitation or terminal restlessness, several therapies have demonstrated clinical effectiveness based upon published randomized clinical trials. Medications found to be effective for the management of agitation in advanced illness, particularly dementia, include antipsychotics, citalopram, benzodiazepines and dextromethorphan/quinidine. For refractory agitation not responding to other treatments, phenobarbital may be a therapeutic option. Importantly, common agitation-related symptoms such as calling out/shouting, repetitive movements and day/night reversal should not be considered for antipsychotic therapy.

Scoring of the Minimum Data Set 3.0 at the End of Life

When an antipsychotic is given and the resident dies in the nursing home, the discharge screen does not ask whether the resident received an antipsychotic, and thus the antipsychotic does not impact the quality measure. If, however, the resident is discharged alive—for example to the hospital—the question of whether the resident received an antipsychotic is asked. Election of hospice is not adjusted for this measure. For the comfort and well-being of the resident and for the least impact on quality measures, it is beneficial to help the resident remain in the nursing home.

VITAS Can Help

VITAS has decades of experience caring for nursing home residents near the end of life. Our care plans incorporate a multidisciplinary assessment and management approach to identify and treat contributors to agitation and terminal restlessness, such as pain, shortness of breath, anxiety, depression and constipation. As part of our patient-centered care plan, VITAS offers non-pharmacologic sensory therapies. Also, Intensive Comfort Care® provides shifts of care for appropriate patients up to 24 hours during difficult times so your resident remains at the nursing home and out of the hospital.

At VITAS, patients and families come first. We choose partners who have the same values. Together we can ease the burdens and grief at the end of life through appropriate administration of medications.

Disclaimer: Each patient’s situation is unique. While this has been created for clinicians, it cannot replace the professional judgment of a physician or other healthcare professional.

Oncologists Refer Patients Earlier to Hospice after Simple Quality Improvement Project

Wed, 22 Feb 2017 00:00:00 -0500

Treating Referrals as Quality Measures

By treating referral for hospice care as a quality measure, an Ohio healthcare system has seen the doubling of the hospice length of stay (LOS) among cancer patients referred by its oncologists in private practice, from a median of 19.7 days to a median of 39.6 days—and all within one year, according to a report on the project presented at the 2016 Palliative Care in Oncology Symposium in September.

"We needed to move an entire health system toward more routine, more systematic, and less variable care," explains project leader Charles F. von Gunten, MD, PhD, vice president of medical affairs, hospice and palliative medicine for OhioHealth, a system serving central Ohio. "It starts with the fact that hospice has been proven to be the best care at the end of life."

The key issue was how to reach all of the hospice eligible patients, notes von Gunten. "Our novel thought was whether we could treat referral for hospice care as a quality measure. "The researchers concluded that they could, with striking results. "Treating hospice care as a measure of quality showed that the length of stay doubled," says von Gunten. "This shows that something as simple as a quality improvement project can change behavior."

A Novel Quality Improvement Approach

The OhioHealth system contains clinical guidance councils, which set the standards of care for various specialties within the system. The oncology council is composed of medical, surgical, gynecological and radiation oncologists. This council was polled for a consensus on how long a patient with cancer should be enrolled in hospice. 64% of council members thought the median LOS for cancer patients should be 90 days; 20% thought is should be 45 days.

The council then sent letters to community medical oncologists (n = 18), informing them of the council's opinion that the optimum hospice LOS was 90 days and noting that the national median was only 43 days, based on current information from the National Hospice and Palliative Care Organization. The letter also included a graph illustrating each oncologist's current LOS for referred patients and how it compared with that of their peers.

"As a group, physicians are competitive. They like data and like knowing the numbers," notes von Gunten, who is himself a medical oncologist. "So, seeing their own performance and those of their peers, and being compared to benchmarks and standards—this was the core of our intervention."

Key Findings

At baseline, the median LOS for cancer patients (n= 176) referred in 2014 by community oncologists was 19.7 days.
Following the intervention, the median hospice LOS for patients (n = 133) referred in the first 10 months of 2015 was 39.6 days.

"The conclusion I reached from this study is that medical oncologists want to do the right thing," says von Gunten. "They are somewhat unsure of when to refer for hospice care and worry that they may refer too soon rather than too late. "By showing them the data, I was confirming that they were not referring patients too soon," he continues. "is project helped them overcome this concern."

As might be expected in a project conducted among real, practicing oncologists, there was a wide variation in results, notes von Gunten, with some improvements as great as an increase from 10 to 45 days for LOS, while some remained the same, and one practice even showed a decrease in hospice LOS (from 22 days down to 15 days).

There seemed to be no resentment at this intervention among the oncologists, observed von Gunten. "Our doctors are accustomed to getting quality data about a number of things, and this project fit the format, style, and tone of those other communications. I was surprised, but there was none of the feeling of 'you're attacking me; I'm doing the best I can.''

The measure is being repeated for oncologists for 2016, with plans for implementing the same intervention through the established clinical guidance councils for other specialists, such as pulmonologists, primary care physicians, hospitalists and cardiologists. "I can hardly wait to check the data later this year," he concludes.

Cosponsors of the 2016 Palliative Care in Oncology Symposium, subtitled "Patient-Centered Care across the Cancer Continuum," include the American Society of Clinical Oncology and the American Academy of Palliative Medicine, the American Society for Radiation Oncology and the Multinational Association of Supportive Care in Cancer.

Source: "A Quality Improvement Approach to Oncologist Referrals for Hospice Care,"2016 Palliative Care in Oncology Symposium, Abstract 45, presented September 10, 2016. Journal of Clinical Oncology; 34(suppl 26S; abstr 45). von Gunten CF; OhioHealth, Columbus, Ohio.

Areas with High Hospice Use Have 'Spillover Effect' of Lower Rates of 30-Day Rehospitalization

Fri, 27 Jan 2017 00:00:00 -0500

The "Spillover Effect"

Patients newly enrolled in hospice close to hospital discharge were found to be at low risk for rehospitalization within 30 days, as is consistent with hospice goals. Further, all hospitalized patients residing in geographic areas with high utilization of hospice were found to be at lower rehospitalization risk than were patients living in areas of low hospice use, according to a report published in the Journal of Palliative Medicine.

What the authors identify as the “spillover effect” of hospice utilization density has been previously observed in the nursing home setting, on patterns of chemotherapy use at the end of life, and among family members of hospice patients, the authors point out. This appears to suggest that the presence of hospice has an impact not only on individual enrollees, but also on and through local systems of care and patterns of practice.

“This work suggests that hospice services are of benefit to both hospice enrollees as well as non-enrollees..., and may be an important component in efforts to improve post-hospital care,” write the authors. “Hospitalizations...represent a critically important point where discussions of care preferences can take place, and where transitions to hospice may improve the quality of care for select patients for whom hospice is consistent with their overall goals.”

Investigators assessed 1,997,506 hospitalizations between 2005 and 2009 from a 5% national sample of Medicare fee-for-service beneficiaries (mean age, 79 years; female, 63%; white race, 87%). Enrollment and claims data were linked via patients’ zip codes to U.S. Census data and Hospital Service Area (HSA), from the Dartmouth Atlas of Health Care.

Hospice utilization was grouped into tertiles according to the percentage of all deaths occurring in hospice within each HSA. Wide geographic variation was found; the proportions of patients who died in hospice, grouped by lowest, middle and highest hospice utilization tertile, were 27%, 41% and 53%, respectively.

Key Findings

18.2% of patients were rehospitalized within 30 days of discharge.
Patients enrolled in hospice near or at discharge had lower rates of 30-day rehospitalization than did non-hospice patients (2.2% vs 18.8%).
Rehospitalization diagnoses were similar among hospice enrollees and non-enrollees, with congestive heart failure, septicemia and pneumonia being the most prevalent diagnoses.
Hospice enrollment within 30 days of hospital admission was associated with a reduced risk of rehospitalization (adjusted hazard ratio [HR], 0.12; 95% confidence interval [CI], 0.12 to 0.13).
Patients living in areas of low hospice utilization had greater risk of hospitalization compared with those patients living in high-utilization areas (19.1% vs 8.1%; HR, 1.05; 95% CI, 1.04 to 1.06).
The effect of hospice enrollment in reducing rehospitalization risk remained constant, regardless of the number of a patient’s prior hospitalizations (P = < 0.001).

Recurrent hospitalizations at the end of life and the high-intensity care that accompanies them often serve only to reduce patient quality of life and reduce the likelihood that patient preferences will be honored, such as for comfort care and dying at home, note the authors. Hospice care helps reduce unwanted and burdensome rehospitalizations by helping patients and families to realign expectations for care.

“Hospice, by providing comprehensive patient- and family-centered care for seriously ill patients nearing the end of life, facilitates a transition to primarily home-based, holistic care focused on comfort and quality of life that is personalized to the individual patient’s goals of care,” the authors write.

“Hospice additionally provides an immediate and always accessible on-call service for symptom management and acute changes in status that may preclude emergency medical services activation, emergency department evaluation, or rehospitalization.”

Source: “Hospice Enrollment, Local Hospice Utilization Patterns, and Rehospitalization in Medicare Patients,” Journal of Palliative Medicine; July 2015; 18(7):601-612. Holden TR, et al; Departments of Medicine, Population Health Sciences, Family Medicine, Surgery and Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, WI.

10 Ways to Reduce Patient Readmissions

Thu, 12 Oct 2017 00:00:00 -0400

Communication and collaboration are the keys to reducing patient rehospitalization. Studies suggest that healthcare professionals, including physicians, hospital leadership, and assisted living or skilled nursing facility administrators, can avoid unnecessary and costly readmissions by working together.

Although predicting which patients are at risk for readmission is not an exact science, there are some concerns cited by patients themselves that healthcare professionals have begun addressing:

Feeling unprepared for discharge
Difficulty performing activities of daily living
Trouble adhering to or difficulty accessing discharge medications
Lack of social support

10 Strategies for Reducing Hospital Readmissions:

1. Quality first. It’s simple, but true. Care for patients correctly and:

readmission rates fall
performance on quality measures improves
savings are realized

2. Begin care management and discharge planning early. Keep the flow of communication going across the coordinated care team, including family members, primary care providers and staff at the patient’s ALF or SNF. Make post-discharge appointments for follow-up care before patient is discharged. Make post-discharge phone calls soon after discharge, so a team member can assess the patient’s condition and answer questions.

3. Review medications face to face. Physicians caring for the hospitalized patient should review all of the patient’s medications and give the patient clear, explicit instruction on how to properly take them.

4. Use teach-back techniques to ensure patient education. Educate patients and their families in managing the health condition, but at a level appropriate to them. Ask patients to “teach back” or explain the information they’ve been given.

5. Use health information technology. Barriers exist that make it difficult for primary care physicians (PCPs) to help manage the handoff from the inpatient to outpatient setting. With a universal health record, the PCP can easily and quickly find out what transpired in the hospital.

6. Enhanced training for SNF/ALF staff. Assisted living and skilled nursing facilities that provide training to their clinical staff reduce hospital admission and readmission rates. A training program should be implemented to help staff identify and address early changes in a resident's health ad mental/functional status.

7. “SNFists.” The availability of physicians, nurse practitioners or physician’s assistants on-site to perform an immediate assessment of acute changes in the clinical status of skilled nursing facility residents is invaluable to avoiding unnecessary hospitalizations.

8. Community paramedicine. Community paramedicine can be a good fit in a hospital’s overall plan to reduce readmissions, particularly in rural or under-served areas. Emergency Medical Services are already established in communities. With extra training, paramedics can expand the scope of their practice to provide home visits and health services to patients at risk for readmission.

9. Advance directives. Knowing what care patients want at the end of life can provide treatment direction, options and choices when a patient has a change in healthcare status. Patients often prefer the option of staying in place rather than going to the hospital. Advance directives should be documented and on file so the clinical staff and physician know the patient’s wishes.

10. Palliative care and hospice. For appropriate patients, hospice and palliative care offer a more dignified and comfortable alternative to spending their final months going back and forth to a hospital. Hospice provides care to patients in their homes—whether the home is a private residence, an assisted living community or a skilled nursing facility. A hospice team of physician, nurse, aide, social worker, chaplain and volunteer manage the patient’s pain and symptoms and give social, emotional and spiritual support to the patient and family.

Homebound Status May Predict Mortality Among Older Adults

Wed, 14 Feb 2018 00:00:00 -0500

Among adults aged 65 years and older living in the community, homebound status is associated with greater risk of death, independent of functional impairment and comorbidities, according to findings published in the Journal of the American Geriatrics Society. Further, half of older adults studied were homebound in the year before death.

“Two-year mortality was greater than 40% in homebound individuals, and half of community-dwelling Medicare beneficiaries are homebound in the last year of life,” write the authors.

“Identifying homebound older adults and offering them medical care where they need it will only become more important as the population ages.”

Investigators analyzed the in-person interview responses of community-dwelling older adults (n = 6,400) enrolled between 2011 and 2013 in NHATS (the National Health and Aging Trends Study), an examination of trends in late-life disability and functioning among a nationally representative cohort of Medicare beneficiaries.

To date, definitions of older adults’ homebound status have been based on their use of Medicare home health services rather on the frequency with which they leave their house, the authors note. For the purposes of this study, participants living in home settings other than nursing homes were classified into one of the following three categories of homebound status:

Homebound: respondents who reported they left their home never or rarely within the past month
Semi-homebound: participants who left home, but with assistance or with difficulty doing so on their own
Non-homebound: participants who left home without help or difficulty

“This article is the first, to the authors’ knowledge, to describe the effect of homebound status on mortality in a US population,” write the authors. They propose that gaining an accurate estimate of mortality risk associated with homebound status is “an important first step in differentiating homebound status from functional status in predicting mortality in older adults.”

Overall Findings

50.9% of community-dwelling older adults were homebound in the last year of life.
At two-year follow-up, 40.3% of homebound participants and 21.3% of semi-homebound participants had died; only 5.8% of non-homebound participants had died.

The finding that half of all participants were homebound in the year before death “suggests that half of Medicare beneficiaries will have difficulty accessing office-based care when they have the most need,” the authors observe. They suggest that older homebound patients’ restricted access to care could be addressed by increasing home-based palliative care, which has been shown to benefit patients through improved quality of life and decreased hospitalizations.

Non-Homebound vs Homebound

Compared with non-homebound individuals, the homebound and semi-homebound participants were:

Older (84.0 and 80.6 years old, respectively, vs 76.5 years old)
More likely to be female (73.0% and 66.3% vs 53.1%)
More likely to be nonwhite (32.4% and 23.7% vs 16.7%)
Burdened with more chronic diseases, including higher rates of probable or possible dementia (62.4% and 37.7% vs 14.0%) and depression (46.1% and 27.0% vs 10.1%)
More likely to be dependent in one or more self-care activities (65.5% and 40.2% vs 5%) and dependent in at least one household activity (78.4% and 55% vs 7%; all, P < 0.001)

Mortality Risk

One-year mortality for homebound participants was 21%; two-year mortality was 40.3%.
In unadjusted analysis, both homebound and semi-homebound status were strongly predictive of two-year mortality (hazard ratio [HR] 8.85; 95% confidence interval [CI] 7.30–10.73 and HR 4.08; 95% CI 3.29–5.06, homebound and semi-homebound respectively).
After adjustment for factors such as demographics, functional status, comorbidities and social support, homebound status remained strongly associated with a greater likelihood of two-year mortality (HR 2.08; 95% CI 1.63–2.65; P < 0.001).

“Homebound status is associated with greater risk of death independent of functional impairment and comorbidities,” the authors conclude. “To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals.”

Source: : “Two-Year Mortality in Homebound Older Adults: An Analysis of the National Health and Aging Trends Study,” Journal of the American Geriatrics Society; January 2017; 65(1):123-129. Soones T, Federman A, Leff B, Sui AL, Ornstein K; Department of Geriatrics and Palliative Medicine; Division of General Internal Medicine, Department of Medicine; and Institute for Translational Epidemiology, Icahn School of Medicine at Mount Sinai, New York City; Division of Geriatric Medicine, Department of Medicine; Department of Community and Public Health, School of Nursing; and Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore; and Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York.

Families Rate Hospice as “Excellent” with Highest Ratings Linked to Longer Lengths of Stay

Thu, 25 May 2017 00:00:00 -0400

Family members of patients with advanced cancer who died while under hospice care were more likely to report that their loved ones received appropriate symptom relief, had their wishes honored and died in their preferred location than were relatives of nonhospice patients. Further, the earlier patients were referred to hospice, the higher the families’ approval ratings, according to a report published in the Journal of Clinical Oncology.

“Overall, longer hospice stays were associated with family perceptions that patients received ‘just the right amount’ of pain medication, greater patient-goal attainment and higher rates of family-reported excellent quality of end-of-life (EOL) care, compared with short stays,” write the authors. “Together, our findings suggest that encouraging hospice enrollment, particularly enrollment weeks before death, may improve EOL experiences of patients with cancer.”

Investigators analyzed interview responses of bereaved family members (n = 1,970) of 985 matched pairs of patients with advanced lung or colorectal cancers who had died either with or without hospice care. Patient data were derived from the Cancer Care Outcomes Research and Surveillance (CanCORS I and II) studies, in which nationally representative participants from five U.S. geographic regions were enrolled from 2003 through 2005 and followed through 2011.

The median length of hospice stay was 21 days (interquartile range, seven to 56 days) among all 1,257 of those enrolled, out of a total of 2,307 decedents in the study whose relatives completed post-death interviews. More than one-third (36%) of patients were under 65 years of age, with a wide range of insurance types.

Key Findings

Hospice patients were more often perceived as receiving “just the right amount” of pain medicine than were nonhospice patients (80% vs 73%).
A higher percentage of patients in hospice than of those without hospice were given “just the right amount” of help with dyspnea (78% vs 70%).
Patients enrolled in hospice were more likely to have their EOL wishes followed “a great deal” than were those not in hospice (80% vs 74%).
Hospice enrollees were more likely to die in their preferred place than were nonhospice patients (68% vs 39%).
More hospice patients’ than nonhospice patients’ overall EOL care was rated as “excellent” by their families (57% vs 42%).

Lower Likelihood of Inappropriate Amount of Care with Hospice

Families of hospice patients were less likely than nonhospice families to report that “too little” pain medicine was given (8% vs 11%).
Families were less likely to report that hospice patients received “less help than wanted” with dyspnea than were nonhospice families (12% vs 18%).
Families of patients in hospice were not more likely than families of nonhospice patients to report the receipt of “too much” pain medicine (10% vs 11%).

Hospice patients’ symptoms were better controlled overall, point out the authors, despite the observation that hospice patients had a higher symptom burden than those who did not die under hospice care. “Of note, the families of patients enrolled in hospice were not more likely to report that patients received ‘too much’ pain medicine, rather they were more likely to report that patients received ‘just the right amount,’” they write.

Importance of Hospice Length of Stay

Families of patients enrolled for > 30 days more frequently reported that their loved ones received “just the right amount” of pain medicine compared with those enrolled ≤ 3 days (85% vs 76%) and were more likely to rate the overall quality of care as “excellent” (65% vs 50%).
Family members of patients in hospice for > 30 days were more likely to report that the patients’ EOL wishes were followed “a great deal” compared with patients enrolled ≤ 3 days (87% vs 79%).
The earlier the hospice enrollment, the greater the likelihood that patients would die in their preferred place (> 30 days in hospice, 75%; eight to 30 days in hospice, 67%; four to seven days in hospice, 61%; ≤ 3 days in hospice, 48%).

Because so many U.S. patients with advanced cancer are enrolled within three days of death, the finding of the beneficial effect of the duration of hospice enrollment takes on great importance, note the authors. “Families of patients who received more than 30 days of hospice care reported the highest quality EOL outcomes,” they write.

“Although early hospice enrollment may not be possible for all patients, our data suggest that more attention should be focused on efforts to enroll patients with cancer into hospice earlier, because the median length of stay for patients enrolled in hospice care in the United States is only 17.4 days.”

Source: “Family Perspectives on Hospice Care Experiences of Patients with Cancer,” Journal of Clinical Oncology; February 1, 2017; 35(4):432-439. Kumar P, Wright AA, Hatfield LA, Temel JS, Keating NL; University of Pennsylvania, Philadelphia; Harvard Medical, Boston; and Brigham and Women’s Hospital, Boston.

Dying COPD Patients Receive Increasing Rate of Life-Sustaining Procedures over Time

Wed, 15 Aug 2018 00:00:00 -0400

Among patients with chronic obstructive pulmonary disease (COPD) hospitalized at the end of life, the utilization of life-sustaining procedures such as mechanical ventilation and cardiopulmonary resuscitation (CPR) showed a significant interval increase from 2010 to 2014. Over the same time period, the documentation of do-not-resuscitate (DNR) status also increased significantly, while the use of palliative care consultations increased only slightly.

“To the best of our knowledge, this is the first study to report the five-year national temporal trends of life-sustaining procedures and palliative care for dying patients with COPD in US hospitals,” write the authors of a study published in the Journal of Palliative Care.

Investigators analyzed data from the National Inpatient Sample, a nationally representative database, on 38,425 adults with COPD (mean age, 73.1 years; female, 53.5%; white race, 82.5%) who died while hospitalized from 2010 to 2014. Temporal trends were quantified using the compound annual growth rate (CAGR).

Overall, 48.9% of dying COPD patients had at least one life-sustaining procedure. 38.6% received a palliative care consultation and 33.7% had a recorded DNR status.

Key Findings:

The rate of patients undergoing multiple life-sustaining procedures increased over time (CAGR: 6.61%), while the rate of those with no such procedures decreased (CAGR: -9.73).
The CAGRs of all life-sustaining procedures increased (dialysis, 13.2%; CPR, 11.99%; vasopressor use, 11.95%; ventilation, 5.45%), with the exception of nutrition (-7.69%)
Both DNR status (CAGR: 36.62%) and palliative consultation (CAGR: 5.25%) increased over time.

In multivariate analysis, occurrence of a palliative care consultation increased the likelihood of DNR status (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.44 to 1.56) and decreased likelihood of local procedures (OR, 0.72; 95% CI, 0.69 to 0.77), systemic procedures (OR, 0.69; 95% CI, 0.64 to 0.73) and surgeries (OR, 0.65; 95% CI, 0.61 to 0.70).

Increase in Aggressive Procedures

Possible reasons for the upward trend in the use of aggressive procedures, note the authors, include not only technological advancements and the increased number of available ICU beds, but also late referral to hospice or hospital based palliative care for patients admitted due to disease progression.

“Life-sustaining procedures almost always initiate until the goal of care is firmly established by the patient or by the healthcare proxy,” they write.

Challenges to timely palliative/hospice care referral of COPD patients include a lack of end-of-life communication, prognostic difficulty, diverse patient characteristics and a lack of resources, the authors note.

Limitations to their analysis noted by the authors include their inability to assess whether those patients who received palliative care consultations would choose home hospice care and whether temporal trends were influenced by the recent Medicare billing code changes that allow clinicians to bill for advance care planning discussions.

Earlier Palliative Care Needed:

According to the authors of an editorial accompanying the report, while the increase in the rate of palliative care consultations for dying COPD patients found in this study may seem encouraging, it is important to keep in mind that the presence of palliative care teams in US hospitals also increased during the study period.

What the editorial authors find “alarming” is that the rate of increase in invasive, life-sustaining procedures used for these dying COPD patients outpaced the rate of increase in palliative care delivery. Initiating a palliative care consult for patients already hospitalized near death is “too late,” they note.

“[E]xpert end-of-life care is but a drop in the ocean of what palliative care can offer for patients with COPD and their caregivers,” write the commenters. “The continuum of care model instead teaches us that palliative care should be instituted early in serious illness to provide comprehensive physical, emotional, social, and spiritual support alongside proactive end-of-life planning.”

The editorial writers conclude, “Pulmonologists who care for patients with COPD from diagnosis and through the end of life are uniquely poised to implement early palliative care in COPD to address the unmet symptom and advance care planning needs of patients with COPD and their family caregivers.”

Source: “Life-Sustaining Procedures, Palliative Care Consultation and Do-Not Resuscitate Status in Dying Patients with COPD in US Hospitals: 2010-2014,” Journal of Palliative Care; July 2018; 33(3):159-166. Shen JJ, Ko E, Yoo JW et al; Department of Healthcare Administration and Policy, University of Nevada Las Vegas, Las Vegas, NV; School of Social Work, San Diego State University, San Diego, CA; and Department of Family Medicine and Department of Internal Medicine, University of Nevada Las Vegas, LasVegas, NV.

“Easing the Tension between Palliative Care and Intensive Care in Chronic Obstructive Pulmonary Disease,” ibid.: pp. 123-124. Iyer AS et al; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine; and Health Services, Outcomes and Effectiveness Research Training Program, University of Alabama at Birmingham, Birmingham, AL.

How We Help Our Healthcare Partners Achieve the Triple Aim

Tue, 26 Sep 2017 00:00:00 -0400

By Nick Westfall, Chief Executive Officer, VITAS Healthcare

Triple Aim provides the opportunity for different providers across the health care spectrum—acute and post-acute—to improve patient outcomes while reducing cost through appropriate transitions of care at the right time based upon a patient’s goals of care. Our goal as the nation’s largest hospice provider is to further align palliative and hospice care across the healthcare continuum while also helping patients and their families appropriately and thoughtfully transition into the hospice benefit at the right time.

Decades of research continues to demonstrate that the building blocks of hospice are designed to achieve exactly what the Triple Aim is designed to do - improve the health of populations, particularly the older adult and terminally ill, through an enhanced patient experience that simultaneously lowers Medicare spending per beneficiary across the care continuum. Patients near the end-of-life and their families seek high quality care at the right place and the right time, and the majority is able to have it provided in their setting of choice, at home surrounded by loved ones. VITAS helps hospitals achieve the Triple Aim by acting as a trusted partner to coordinate discharge planning and transition of care from the hospital facility onto the hospice benefit.

A number of studies document that 80 to 90 percent of people prefer to die at home, and unfortunately only one-third are currently able to do so. This is where a mature, end-of-life provider such as VITAS can partner with hospitals (and all healthcare providers) to help transition hospice-appropriate patients efficiently to the appropriate setting. Recent studies have highlighted that 30 percent of patients who have passed had a visit to the ICU in their last month of life, and 50 percent experience at least one emergency room visit in the last month of life. Hospice provides a great opportunity to transition patients in a more timely fashion, while keeping them comfortable and improving their quality of life. Our patient- and family-centered approach starts with our interdisciplinary team (physician, nurse, aid, social worker, chaplain) throughout their stay on hospice as well as provides bereavement support for that patient’s family upon death, which VITAS provides indefinitely as long as any family member desires this support.

From a cost perspective, the Journal of the American Geriatrics Society published a study last year that found one-third of Medicare beneficiaries go through four or more transitions of care in the last six months of life. This can include transitions between the hospital, nursing home, home health and hospice, which generally does not align with patient and family goals, provides poorer quality of care, and is not cost-effective. VITAS and other post-acute providers can help reduce the cost of healthcare by working together to eliminate unnecessary and often burdensome transitions.

A Kaiser Foundation study recently illustrated that roughly 25 percent of all traditional Medicare spending for healthcare takes place in the last year of life. By partnering with other healthcare providers, we can help them achieve Triple Aim; in fact, a Health Affairs study shows roughly $2,500 lower overall costs in patients who elected hospice compared to those who did not prior to death. Another study that focused on oncology patients published in the Journal of the American Medical Association found those who died with the benefit of hospice cost about $8,700 per patient less on average compared to those who died without the benefit. Moreover, almost 75 percent of the non-hospice group died in either the hospital or a skilled facility, potentially adversely affecting the hospital’s mortality rate.

By providing robust end-of-life care, as well as helping with care transitions, education and awareness, and advance care planning, VITAS serves as an extension to help our healthcare partners achieve Triple Aim. Our interdisciplinary team can evaluate the patient and coordinate care in the setting of choice and provide high quality care through end-of-life, helping to reduce/eliminate unnecessary hospital emergency room visits and hospital readmissions.

We leverage mobile technology to not only assist our employees across the country, but also work seamlessly with other providers to build interoperability with their EMR/EHR systems. When a hospice patient is identified, we can effectively and efficiently use our electronic platform to deploy our care team, admissions nurses and patient concierges to coordinate the discharge process.

We will continue to expand our interoperability platform, which will benefit our partners as they become more incentivized to coordinate a hassle-free, timely transition of care. We continue to make significant investments around our business intelligence and enterprise data warehouse capabilities to provide a mature platform to securely and dynamically share outcome-based information for all of our healthcare partners throughout the country. We are able to share information with physicians and health systems which refer patients to VITAS in the event that they want to measure the benefits of appropriately identifying and coordinating end-of-life care within how they measure themselves for Triple Aim.

In all value-based reimbursement models, our partners would have a vested interest in whether we took appropriate care of patients through providing a cost-effective setting of care, while improving their overall quality and satisfactions scores. We can share this information with them in a secure, HIPAA-protected fashion, providing transparency to all.

Since the inception of VITAS, we have measured our results on all three dimensions of Triple Aim - improving the patient experience, improving the health of populations and reducing the per capita cost of health care - as each of these dimensions reflects the purpose of the hospice benefit.

This message also appeared in the South Florida Hospital News and Healthcare Report in July 2017.

How to Help your Seriously Ill Veteran Patient

Wed, 10 May 2017 00:00:00 -0400

Become Aware of Your Patient’s Background

How many healthcare professionals caring for patients with serious progressive illness are even aware of their patient’s military background? How many doctors would know, when symptoms increase and treatments are no longer effective, that uncontrolled pain and anger, or nightmares, may be delayed or undiagnosed post-traumatic stress disorder (PTSD)?

Not enough. Considering that, according to the VA, half of the men who die today are military veterans*, and that 85 percent of veterans receiving end-of-life care are outside the VA system, there are a lot of veterans who would benefit from hospice services that are designed to meet the unique needs of veterans.

Hospice Treats Veterans’ Unique Needs

Hospice professionals are trained to understand veterans’ unique needs at the end of life and guide these men and women toward a more peaceful death. This is especially important for veterans who experienced combat service or other trauma, because experiences from the past often resurface near the end of life.

In recognition of this, the National Hospice and Palliative Care Organization (NHPCO) and the Department of Veterans Affairs (VA) have initiated a pioneer project: “We Honor Veterans” focuses on respectful inquiry, compassionate listening and grateful acknowledgment of veterans. VITAS is a partner in “We Honor Veterans” and we are recognized for our dedication to veterans.

Physical and Emotional Effects of Military Service

The toll of war can include diseases, disabilities and illnesses that complicate end-of-life care. Depending on the war, veterans may have been exposed to ionizing radiation, Agent Orange, open-air burn pits, battlefield transfusions, below-freezing temperatures and infectious diseases.

These exposures put them at a higher risk for a variety of cancers, type 2 diabetes, kidney disease, heart disease, hepatitis C, respiratory illnesses, malaria, TB and more. Veterans can also suffer from co-morbidities such as PTSD, depression, alcoholism, drug addiction and mental illness.

In addition to physical and psychological conditions, emotional concerns may arise, such as feeling the need to purge themselves of memories by discussing their military experience with family members, sometimes for the first time. Veterans also have concerns about their families and how they will manage after the veteran dies.

Here’s What a Hospice Provider Should Offer to Veterans

A streamlined referral and admission process
Familiarity with the VA system and how to identify and access benefit options for veterans
Coverage of hospice care for veterans by the VA, TRICARE, Medicare, Medicaid, private insurance and other forms of reimbursement
Coordination of care with the staff of the local VA medical center, including joint visits when appropriate
Staff trained to function as communications contacts and primary educational resources to the VA and local veteran organizations
Referrals for additional community services as needed
Bereavement support, including grief and loss programs, support groups and memorial services, for veterans’ loved ones
Recognition and celebration of important events such as Veteran’s Day and military anniversaries

If you have a seriously ill patient who is a military veteran, talk to the patient and family about whether they are using or have questions about their VA benefits. Then get a hospice provider involved that can help the family navigate the VA system, and help your patient feel respected and listened to as he or she approaches the end of life.

*http://www.npr.org/2015/01/28/382218316/end-of-life-care-can-be-different-for-veterans

Hospice Nutrition and Hydration for Your Patients

Thu, 26 Jul 2018 00:00:00 -0400

Hospice care requires hard conversations that lead to difficult decisions by healthcare professionals and their patients and families. One of the most challenging discussions is about initiating, maintaining or withdrawing artificial nutrition and hydration (ANH) as a patient nears the end of life.

Such decisions are complicated by multiple medical guidelines and ethical issues, and compounded by patients’ and families’ emotions, their difficult questions about withholding food and water at the end of life, and the religious, cultural, spiritual and personal influences that surround a loved one’s imminent death.

Healthcare professionals can navigate these difficult decisions by engaging in conversations that are informed by their expert medical-clinical skills and guided by empathy.

Develop an Individualized Hospice Care Plan

Advance care planning represents an ideal approach with a patient and family to elucidate wishes and values before the patient becomes unable to state their preferences. Clinicians can educate patients and families about the natural dying process, including the role of ANH. The hospice care team can be an invaluable resource to facilitate such conversations so that medical, ethical and professional standards are met.

Because each patient’s disease, goals of care and needs are different, decisions about ANH should always be made after a thoughtful, honest and informative conversation that addresses:

The patient’s specific diagnosis and prognosis: How will nutrition/hydration affect both?
Medical issues: What are the indications for or against ANH?
Non-medical issues: What are the patient’s/family’s personal, cultural and religious beliefs and values? How can they be honored within a hospice care plan?
Quality of life: Will artificial feeding/hydration increase or decrease suffering?
Goals of care: Will care-related decisions support the patient’s wishes and values?

Educate Family Members About the Dying Process

Current evidence does not support the contention that withholding food and water at the end of life contributes to suffering and/or life prolongation. Such evidence should be incorporated into goals of care conversations and in the development of an individualized hospice care plan. As a patient’s status changes, so, too, should the hospice care plan.

Doctors and nurses must address emotional issues, too, by reminding families that they are not “giving up on” or “starving” a hospice patient who stops eating or drinking. Instead, clinicians should educate patients and families about the body’s natural dying process, which includes the shutting down of the digestive tract and an increasing inability to process food and fluids. Families can be reassured in the knowledge that as food and water intake slows, the patient’s body often releases “feel-good” endorphins as its own natural form of pain relief.

Tube Placement: Benefits vs. Risks/Complications?

General guidelines address feeding tubes for hospice patients:

Existing feeding tube: If patients are admitted to hospice with feeding tubes already in place, doctors should work closely with patients, families and caregivers to decide if and when to decrease or discontinue ANH. As one approaches end of life, ANH can contribute to discomfort, aspiration and development of pressure ulcers without the benefit of prolonged survival.
Placing a feeding tube: Generally, feeding tubes are not placed in patients once they are enrolled in hospice care. On rare occasions, a decision to proceed with feeding tube placement is made in conjunction with the patient, family and hospice interdisciplinary team.

In general, studies demonstrate that ANH does not prolong life or increase longevity, but it can be associated with numerous complications that diminish the patient’s quality of life. Common complications include irritation, infection, blockage, discomfort, aspiration pneumonia, bleeding, reflux, uncontrolled diarrhea, limited socialization/movement, frequent tube replacement/removal, lack of appropriate oral care, and increased use of physical and/or chemical restraints. Tube feeding at the end of life also can create patient sensations of “drowning” or uncomfortable fullness.

As an example of diagnosis-dependent guidelines, the American Geriatric Society, American Academy of Hospice and Palliative Medicine, and The Society for Post-Acute and Long-Term Care Medicine do not recommend feeding tubes for patients with advanced Alzheimer’s/dementia. Instead, oral assisted feeding is recommended.

Common Questions from Healthcare Professionals about End-of-Life ANH

Do feeding tubes prevent malnutrition? Not necessarily. Many people on hydration and feeding tubes still experience malnutrition as a result of the underlying disease, immobility and neurologic deficits—not a lack of food/water.
Do feeding tubes prevent pressure sores or hasten their healing? Artificial nutrition/hydration can increase urine output, stools, diarrhea, upper airway secretions, and immobility—all of which can exacerbate pressure sores or interfere with healing of existing sores/lesions.
Do feeding tubes decrease the mortality rate? According to studies, life expectancy is nearly identical in patients who are offered end-of-life ANH and those who are not.
Do feeding tubes prevent aspiration pneumonia? Current data does not show that feeding tubes decrease the risk of aspiration pneumonia or regurgitated gastric contents. In fact, some studies indicate increased risk of aspiration as patients with tubes can still aspirate gastric contents and oral secretions, or suffer aspiration pneumonia from other organic causes.

Educate Families About End-of-Life Care

Healthcare professionals are advised to encourage family members to follow accepted hospice guidelines around food and water at the end of life:

Offer small sips of water/liquids, ice chips, hard candy or very small amounts of food via spoon if the patient can still eat or drink. Take cues from the patient when to stop.
Keep a patient’s lips and mouth moist with swabs, a wet wash cloth, lip balm or moisturizers if they are no longer able to drink.
Encourage family members to provide alternative forms of nourishment: conversation, loving touch, music, singing, poetry, humor, pet visits, gentle massage, reading, prayers or other acts of caring and love.

Dealing with Stress When You Work with Death and Dying

Tue, 04 Apr 2017 00:00:00 -0400

Remaining Healthy

Helping patients and their families through the difficult process of death and dying is incredibly rewarding. It is also incredibly stressful. It’s important that you and your team remain healthy during emotionally stressful times.

If more than 3 of these apply to you, you might be suffering from compassion fatigue.

I feel my patient’s stress deeply.
I find small changes draining.
I have lost my sense of being hopeful.
I have outbursts of anger or irritability.
I feel tired and rundown because of my work with patients, families and co-workers.
I find it difficult to separate my work and personal lives.
I feel overwhelmed by unfinished personal business.
I have difficulty falling or staying asleep.
I feel like a failure as a helper.

How to Relieve Stress

You can relieve some stress by taking time out of your busy schedule to focus on you. Do it with a clear conscious; you can’t afford not to.

Here are a few helpful tips to get you started:

Your health is important too. Take care of yourself by eating well, sleeping well and participating in hobbies or activities that get your mind off work, like exercising or enjoying time with friends or family.
Take regular, short breaks throughout the day. Small breaks from your daily workload, like going out for a ten-minute walk or having a late-afternoon snack, can help ease stress and improve both your mood and your work.
Foster a support system, both at and outside of work. Let your colleagues know how you are feeling and ask how they are doing. A sense of camaraderie and support can be very positive in the workplace. If you feel it might help, reach out to a clergy member or professional counselor for advice and comfort.
Remember that your work is valuable. What you do for patients and their families is meaningful. But death and dying are stressors, and it can be easy to forget that your daily work brings quality of life to the end of life.

Stress is a very natural response to living and working so close to dying and death. An honest assessment of your stress levels and following steps to manage that stress can help you both professionally and personally.

Preventing Falls in Elderly Patients Can Avoid Injury and Save Lives

Thu, 23 Aug 2018 00:00:00 -0400

It happens quickly and without warning. One moment, your elderly patient is standing upright, leaning against a chair, sitting on the edge of a bed or walking slowly … and the next minute, the patient is on the ground.

On average, an older American falls every 17 seconds, making falls a leading cause of injury and the leading cause of injury-related death among people 65 and older, according to the US Centers for Disease Control.

People of all ages can lose their balance or trip for any number of reasons, but falls in the elderly are typically the result of three kinds of factors: environmental, personal and health/medications.

Identify Risk Factors, then Take Action

Here’s a look at what causes falls and how to reduce their incidence:

Environmental Factors: Falls can often be linked to inadequate lighting, cluttered stairways, slick or irregular floors, uneven area rugs, improperly maintained wheelchairs, inadequate footwear or eyewear, furniture that is too high or too low, and lack of hand grips or supports in bathrooms and at the bedside.
Personal Factors: Age, lack of physical fitness and poor dietary habits contribute to falls. Alcohol, smoking and lack of exercise can decrease bone strength and balance. Inadequate water/fluid intake can deplete strength and energy.
Health Factors: Older people are prone to falls if they are weak, have a history of falls, use an assistive device (such as a cane or walker), have a cancer that affects the bones, are visually or hearing-impaired, are depressed, have dementia/Alzheimer’s disease, exhibit gait limitations, experience cardiac arrhythmias or experience fluctuating blood pressure.
Medication Factors: Some medications are linked to a risk of falls, including sedatives, anti-anxiety drugs, antidepressants and anti-hypertensives. Anti-coagulants/blood thinners and aspirin can lead to excess bleeding or blood loss after a fall.

An Assessment and Fall-Prevention Action Plan

As a healthcare professionals, you and your colleagues should assess elderly patients for their risk of falling. High-risk individuals include those who have a history of falls or falling out of bed, are unable to walk/move safely, cannot transfer safely from a bed to a wheelchair, and are inconsistent about asking others for help.

If patients are at high risk for falls, an interdisciplinary safety care plan should:

Educate the patient, family and caregiver about moving and transferring safely
Assess medication use and consider discontinuing medications that are unnecessary, inappropriate or ineffective
Support the use and installation of assistive devices and safety equipment, including canes, walkers, hand rails, bathtub grips, bed rails, hip protector garments/pads, bed rails, and a regular “look up/look down assessment” to make sure the person is wearing stable shoes and properly fitted eyewear. Portable commodes and urinals should be placed close to an elderly person’s bed.
Encourage physical activity and exercise as tolerated by the patient to increase strength, balance and situational awareness
Monitor patient activity via regular schedules, electronic or baby monitors, and avoidance of the “I’ll be right back syndrome” by caregivers
Remove area rugs and loose/unsafe floor coverings that can cause tripping or interfere with walking/navigating
Provide oxygen (when necessary) to prevent dizziness and confusion
Encourage a healthy diet, including plenty of fluids, no smoking and limited alcohol intake

Falls can evolve very quickly into life-altering, life-limiting injuries. Preventing falls is a far healthier strategy, especially for older patients who are most at risk.

Hospice Referrals for Advanced Dementia Patients Increase

Wed, 14 Feb 2018 00:00:00 -0500

The rate of hospice referrals for hospitalized patients with advanced dementia transferred from nursing homes increased over the past decade, particularly among those whose attending physician was a hospitalist rather than a non-hospitalist generalist or specialist, according to a report published in the Journal of the American Geriatrics Society.

“The increased likelihood of hospice referral for admissions where hospitalists are the attending physician is encouraging, given the growing role of hospitalists in the care of hospitalized older adults,” write the authors. “This ... has implications for how hospice referrals for high-risk patients might be increased.”

Benefits of Hospice for Dementia Patients

Research has shown that patients with advanced cognitive impairment, many of whom reside in nursing homes, derive significant benefits from enrollment in hospice, the authors point out. Patient and family benefits include:

Fewer unmet needs compared with advanced dementia patients not in hospice
Fewer hospitalizations and other burdensome transitions
Improved symptom management
Greater family satisfaction and higher ratings for the quality of end-of-life care their loved ones received

“Despite the benefits of hospice care, there is significant variation in who is enrolled in hospice that is not driven by patient preferences for care,” the authors write. They add that while patient and system characteristics contribute to the occurrence of hospice enrollment, physician characteristic have been shown to be a major predictor.

“This work contributes an additional example of the role of the physician and the health system in determining the care that patients receive at the end of life,” the report says. Investigators analyzed hospice referral patterns in a 20% sample of Medicare nursing home residents with advanced dementia and four or more impairments in activities of daily living who were hospitalized between 2000 and 2010 (n = 128,989). Rates of hospice referral of patients within one day post-discharge were compared among three groups of attending physicians: general practitioners, specialists and hospitalists.

Overall Findings

The rate of hospice referral among hospitalized advanced dementia patients increased from 2.8% in 2000 to 11.2% in 2010.
10.6% of patients died while hospitalized; the mortality rate in the year post-hospitalization was 66.6%.
Over time, all three physician groups had increasing hospice referral rates, from 2.7%, 2.6% and 3.6% in 2000 to 9.9%, 10.2% and 13.8% in 2010 for generalists, specialists and hospitalists, respectively.

Key Role of Hospitalists

Hospitalists were more likely than generalist physicians to refer patients to hospice at discharge (adjusted odds ratio [AOR] 1.27; 95% confidence interval [CI] 1.20–1.40) in bivariate analysis.
Adjustment for the increasing prevalence of hospitalist utilization by facilities over time revealed an even stronger likelihood of hospice referral for patients cared for by hospitalists (OR 1.75; 95% CI 1.50–1.86).
Continuity of care from outpatient setting to hospital (i.e., having cared for the patient within 120 days prior to admission) was linked to lower likelihood of hospice referral (AOR 0.78; 95% CI 0.73–0.85).

“It is interesting that generalists with continuity were less likely to refer persons to hospice, indicating that the presence of fresh eyes might be important to re-evaluate a patient’s clinical course,” note the authors.

Suggested Reasons for Higher Rate of Hospitalist Referrals:

Hospitalists probably care for greater numbers of seriously ill inpatients than do generalists, and may thus have become more comfortable discussing advance care planning and suggesting hospice.
A lack of care continuity with patients may reduce hospitalists’ fears of inducing patient-perceived abandonment and may also improve prognostication.
Hospitalists may be practicing in health systems in which they have greater exposure to palliative care teams, or in systems that encourage hospice referral as a means of reducing readmissions and inpatient deaths.
Due to the relative newness of the hospitalist specialty, these physicians are likely to have benefited in their medical training from the increased emphasis on education in palliative medicine in recent years.

Hospitalist care is also associated with shorter length of hospital stays and other quality outcomes, making it a good target for improving rates of hospice referral, the authors note.

“Understanding the increasingly common hospitalist role as well as hospital-level factors associated with hospitalist utilizations is necessary to understand how we might ensure that the hospice benefit is available for all patients and families who might benefit,” they write.

“Efforts to increase generalist and specialist education around palliative care and collaboration with palliative specialists could mimic some of this exposure and training that hospitalists have,” suggest the authors. In the clinical setting, “interventions such as electronic medical record triggers or triggered palliative care consults could provide this benefit regardless of attending type.”

Source: “Association of Physician Specialty with Hospice Referral for Hospitalized Nursing Home Patients with Advanced Dementia,” Journal of the American Geriatrics Society; August 2017; 65(8):1784-1788. Ankuda CK, Mitchell SL, Teno JM et al; Robert Wood Johnson Clinical Scholars Program, University of Michigan, Ann Arbor; Hebrew Senior Life, Institute for Aging Research, Boston; and Division of Gerontology and Geriatric Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, University of Washington, Seattle.