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Hospice Care: Advocacy and Identification for Optimal Patient Outcomes. Amy Muhlenbruck , BSN, RN Chief Clinical Officer Saint Jude Hospice muhlenbrucka@saintjudehospice.org. Objectives. Understand current state associated with barrier to hospice referral.

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hospice care advocacy and identification for optimal patient outcomes

Hospice Care:Advocacy and Identification for Optimal Patient Outcomes

Amy Muhlenbruck, BSN, RN

Chief Clinical Officer

Saint Jude Hospice

muhlenbrucka@saintjudehospice.org

objectives
Objectives
  • Understand current state associated with barrier to hospice referral.
  • Learn basic regulations associated with hospice care.
  • Learn indicators of common terminal diagnosis and prognosis.
  • Enhance communication strategies for conversations introducing hospice care.
  • Understand hospice care expectations for an assisted living population.
hospice what do we know
HOSPICE: What do we know?

Unique set of benefits for dying patients:

  • Medications, medical equipment (DME), aide services
  • Interdisciplinary Group support (IDG)
    • Medical Director, RN, Spiritual Counselor, Social Worker, Volunteer
    • Care planning
    • Education
  • Families receive emotional and spiritual support and bereavement counseling x1 year following death
what do we know
What do we know?

High-quality care with high levels of satisfaction:

  • Improved pain assessment and management
  • Improved bereavement outcomes
  • Better overall satisfaction
  • Greater satisfaction among families of patients referred to hospice
however
However…

Hospice provides care for only one third of all dying patients

  • Enrollment generally very late in the course of illness
  • Median LOS is approximately 3 weeks
  • 10% of patients enroll in their last 24 hours of life
  • Unknown the proportion of ideal enroll or optimal LOS

Widespread agreement among experts in the field and physicians that more patients could enroll in hospice and many of those who enroll should do so sooner.

barriers to hospice referra l
Barriers to Hospice Referral
  • Medicare Hospice Benefit requirement:
    • Life expectancy of 6 months or less
    • Forgo curative treatments
  • Palliative Care
    • Causes delay in enrollment
    • Reimbursement rate/expensive palliative treatment
palliative care defined
Palliative Care Defined

WHO Definition of Palliative Care

  • Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness.
    • Prevention and relief of suffering by means of early identification
    • Assessment and treatment of pain
    • Other problems: physical, psychosocial and spiritual.
palliative care defined1
Palliative Care Defined

Relief from pain and other distressing symptoms;

  • Enhance quality of life, and may also
  • Positively influence the course of illness.
  • Applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life:
    • Chemotherapy or radiation therapy
    • Includes those investigations needed to better understand and manage distressing clinical complications.
barriers to hospice referral
Barriers to Hospice Referral

Barriers created by the challenges of hospice discussions

  • Patients and Families cannot accept that effective, disease-directed treatment is no longer available or 6 months prognosis
  • Patients or families to have overly optimistic goals and expectations of treatment
  • Even the most careful and persistent communication

efforts often fail to change patients’ and families’ goals

the result
The Result?

Decision to enroll in hospice is unlikely

  • However:Physicians should still discuss the patient’s goals and can use these discussions to introduce hospice

Barriers to physician conversation:

  • Hospice discussions difficult and uncomfortable
  • Asking to “give up” on disease-directed treatment
  • Comfort with “bad news” discussions
  • Time for “bad news” discussions
what clinical criteria determines eligibility
What clinical criteria determines eligibility?
  • Local Coverage Determination (LCD)
  • Used by the National Government Services in reviewing hospice claims
  • Framework to guide determination of hospice eligibility
  • Includes specific eligibility criteria for certain disease categories
    • Disease specific indicators, functional limitations, and contributory co-morbid conditions
    • Continual evaluation of a patient’s terminality status and eligibility for ongoing hospice care
local coverage determination lcds
Local Coverage Determination LCDs
  • Formally called LMRPs – Local Medical Review Policies
    • Changed to LCDs in 2003
  • LCDs are only guidelines
  • Created to assist in determining eligibility based on disease severity (how advanced is it?)
  • Limited prognosis is the only real eligibility criterion

Remember: Don’t ask exclusively about what is the DIAGNOSIS, Prompt conversation to consider true PROGNOSIS.

eligibility vs compassion
Eligibility vs. Compassion
  • Patient assistance with a number of significant problems: medical, psychological, spiritual and social.
  • Patients who do not meet the hospice eligibility guidelines may have these same needs but do not have a six month or less prognosis.

Even though we may wantto provide services to these patients, we have an obligation to admit/certify/recertify only those patients who meet the guidelines set by Medicare.

eligibility vs care provided
Eligibility vs. Care Provided
  • Belief of hospice“Eligibility” is too often related to how much care is provided (how much they “need” us) rather than the actual medical eligibility for the benefit:
    • False belief a patient is eligible because:
      • The nurse sees them 3x a week
      • The aide is helping them to eat
      • The family really needs our help
care required
Care Required
  • This type of documentationmay help to corroborate eligibility but it does NOT define eligibility
  • Eligibility documentationMUSTreflect the Medicare LCD criteria
criteria eligibility
Criteria Eligibility
  • Patients Must Meet 1 of 4 Criteria to be “Eligible”
  • They meet all the Local Coverage Determination (LCD) criteria.
  • They meet most of the LCD criteria and have documented rapid clinical decline suggesting a limited prognosis.
  • They meet most of the LCD criteria andhave significant comorbidities that contribute to a limited prognosis.
  • The physician’s clinical assessment is that the patient has a limited prognosis and is documented.

Confidence in understanding ,

results in patient advocacy and appropriate care.

co morbid conditions
Co-Morbid Conditions

If a patient does not meet all LCD criteria, significant comorbidities must be documented to support the limited prognosis.

  • 6-month prognosis may be appropriate if:
    • Additional organ system involved and
    • There are processes that of themselves limit prognosis but not to the 6-month “terminal” degree.
  • It isn’t the number of co-morbid conditions, it’s the severity that counts.
considerations re co morbid conditions
Considerations re: Co-Morbid Conditions
  • Contribute to health decline, prognosis, and terminality
    • Processes that of themselves limit prognosis but not to the 6-month “terminal” degree.
  • Common conditions that need active management at EOL
    • hypertension, atrial fibrillation, thromboembolic disease, dementia, osteoporosis, diabetes mellitus, and arrhythmia.
  • Both the life limiting illness and comorbidity change clinically over time and therefore need regular review.
  • Hospice Myth – WE DON’T DISCONTINUE ALL MEDS!
co morbid conditions1
Co-Morbid Conditions
  • Examples of co-morbid conditions that may not impact the patient’s prognosis:
    • Amputation
    • Glaucoma
    • Controlled Diabetes Mellitus
    • Controlled hypertension
    • Anything that of itself does not significantly impact the patient’s prognosis is not a valid comorbidity (from an eligibility perspective).
common themes of prognosis
Common Themes of Prognosis
  • The disease process is causing significant disability, despite medical therapy.
  • Recent functional or nutritional decline, or co-morbid diseases significantly effect the prognosis.

“Would you be surprised if the patient passed away this month?”

“Would it surprise you if they lived until Christmas?”

consider the question
Consider the question…

Why hospice?

Why now?

clinical judgment
Clinical Judgment
  • What if there is no specific diagnosis?
  • Elderly with functional impairment, weight loss
  • Usually several chronic illnesses, not clear what will be the cause of death
  • May have a recent acceleration in the decline
  • Elect not to pursue aggressive medical evaluation or treatment due to advanced age or poor medical condition
regulatory considerations for hospice admission
Regulatory Considerations for Hospice Admission
  • Hospice programs must provide
    • Documented evidence that supports admission
    • Continued certification of the terminal illness (CTI) and eligibility
  • Eligibility for benefit provided by a Medicare hospice
    • Eligible for Medicare Part A (Hospital Insurance)
    • Twophysicians must certify the patient’s terminal illness
      • primary physician and the hospice medical director
    • Patient is terminally ill and has 6 months or less to live if the illness runs its normal course
    • Informed Consent
      • Signed statement by patient electing hospice to treat terminal illness
what is certification of terminal illness
What is Certification of Terminal Illness?
  • Often referred to as CTI
  • Social Security Act provides the statutory requirement

(Benefit Periods) for the certification of terminal illness

  • Content of Certification:
    • Certification will be based on the primary care physician (PCP) or hospice medical director’s clinical judgment regarding the normal course of the individuals illness. (No nurse practitioners)

“In the judgment a physician, if the disease runs it’s normal course, death could happen in 6 months or less.”

cti requirements
CTI Requirements
  • Must specify the prognosis is for a life expectancy of 6 months or less, if the illness runs it’s normal course.
  • Clinical documentation supporting the medical prognosis.(not diagnosis)
    • Definitions:
      • Diagnosis: process ofidentifyingthe nature and cause of a disease or injury through examination of patient.
      • Prognosis: A predictionof the probably course and outcome of the disease; likelihood of recovery.
cti requirements1
CTI Requirements

Documentation

  • Filed in the patient’s medical record with written certification.
  • Physician must include brief narrative of findings supporting prognosis <6 months.
  • Physician signature must be present on documentation.
  • Narratives must be written to reflect patient’s unique clinical picture – No Check Boxes!
who decides
Who Decides?
  • Who Decides?
  • On admission:
    • The admitting physician and the hospice medical director must both certify a life expectancy of 6 months or less, if the illness runs the expected course.
    • Certification is based on data from the primary (admitting) physician and the medical record.
    • The decision is clinical using the four guideline criteria.
      • Not just careneeds and unfortunately, not just compassion, qualifies a patient for hospice.
recertification
Recertification

Patient remains “eligible” for hospice services

  • Documentation must support hospice criteria.
  • Decline from admission is not necessarily required unless it is part of the LCD or rapid decline was part of initial certification.
  • Face to Face (F2F) may be required.
f ace to face f2f encounter
Face to Face (F2F) Encounter

CMS Requirement as of January 1, 2011

  • All patients entering their third or later benefit period.
  • Medicare Payment Advisory Commission (MedPAC) concerns
    • High number of patients with lengths of stay <than 180 days
    • Concern that physicians were not as active in the care and treatment of hospice patients as may be required
    • Incorporated into the Patient Protection and Affordable Care Act
    • Healthcare reform law passed by the Congress and signed into law in March 2010.
    • Completed by a hospice physician or nurse practitioner
terminal vs custodial
Terminal vs. Custodial

Payment Review Question:

  • “Is this patient receiving terminal or custodial care?”
  • If documentation doesn’t reflect that the patient is terminal (usually means documenting clinical decline) the hospice is at risk for payment denial.
  • Definition of 'Custodial Care'
    • Non-medical care that helps individuals with his or her activities of daily living, preparation of special diets and self-administration of medication not requiring constant attention of medical personnel. Providers of custodial care are not required to undergo medical training.
clinical decline documentation
Clinical Decline Documentation
  • Multiple recent hospitalizations, emergency room visits, or utilization of other healthcare services
  • Serial assessments (labs, X-rays, etc.) showing progressive illness.
  • Changes in the MDS (Minimum Data Sets) in nursing facility patients.
    • MDS contains items that measure physical, psychological and psychosocial functioning.
    • MDS give a multidimensional view of the patient's functional capacities and helps staff to identify health problems.
  • Progressive deterioration while receiving home healthcare services.
  • Failure of rehabilitation - Skilled
nutrition and prognosis
Nutrition and Prognosis
  • 10% weight loss in elderly, over 6 months associated with high mortality.
    • 62% vs. 9% mortality over 6 months
  • BMI < 22 kg/m2 associated with increased mortality in the elderly.
  • Hospitalized patients with BMI < 20 kg/m2 had the highest mortality in the 6 months post discharge.
nutritional definitions
Nutritional Definitions
  • Cachexia
    • Among most debilitating and life-threatening of nutritional deficits
    • Characterized by
      • Involuntary weight loss, fat and muscle wasting, fatigue, immune dysfunction, metabolic and hormonal dysfunction
  • Anorexia
    • Loss of appetite or desire to eat
    • Frequently accompanies cachexia
  • Anorexia-Cachexia syndrome
    • Common in cancer patients
    • Consistent association with negative clinical outcomes
      • Decreased response to treatment
      • Experience more side-effects
      • Less likely to complete their cycles of chemotherapy
function and prognosis
Function and Prognosis
  • Elderly patients with significant ADL deficits had a median survival of 6 months.
    • 80% 2-yr mortality
  • ADL deficits are the most important predictor of 6-month mortality.
    • Stronger than diagnosis, mental status, or ICU admission.
    • bathing, dressing, toileting, transfer, continence, feeding
pps palliative performance scale
PPS: Palliative Performance Scale
  • Generalizations
  • 50%: mainly sit/lie
    • Requires considerable assistance with ADLs
  • 40% mainly in bed
    • Assistance with all ADLs
  • 30% confined to bed
    • Total care
cancer
Cancer
  • Second Leading cause of death in the U.S.
  • Mass of abnormal cells characterized by:
    • Dysplasia – Abnormality of cell development
    • Hyperplasia – Increased cell production
lcd for cancer diagnosis
LCD for Cancer diagnosis
  • Determine type and location of Cancer diagnosis
    • Class III or IV per medical record
    • Determine distant metastatic site
    • Progressed from earlier stage with an identifier
    • Continuous decline despite treatment
    • Patient decline further disease directed therapy

Note: Certain cancers with poor prognoses may be hospice eligible without meeting LCD criteria

    • Example:
      • Small Cell Lung cancer
      • Brain cancer
      • Pancreatic cancer
cardiovascular disease
Cardiovascular Disease
  • Single leading cause of death in the U.S. today
    • Cardiomyopathies: Diverse group of primary myocardial diseases
      • Approximately half are idiopathic: unknown cause
      • Others:
        • Chronic, high alcohol intake
        • Auto-immune processes, viral infection, inherited tendencies
        • Select medicines causing cardio-toxicity (chemo)
        • Infiltrative disease, fibro plastic diseases
        • Coronary Artery Disease (CAD)
      • Presents as either:
        • Diffuse degeneration of myocardial fibers
        • Hypertrophy or infiltration of the myocardium with fibrous tissues
          • Results in decreased cardiac output
          • HINT: Ejection Fraction (EF)
lcd for cardiovascular diseases
LCD for Cardiovascular Diseases

Review criteria on Determining Terminal Status worksheet

Must have:

  • Congestive Heart Failure (CHF) with NYHA Class IV symptoms
  • Declined invasive treatment

New York Heart Association (NYHA) classification system:

  • Used to determine best course of therapy
  • Used to stage heart failure
  • Relates to everyday activities (functional status)
  • Patients quality of life (QOL)
lcd for cardiovascular diseases1
LCD for Cardiovascular Diseases

Review criteria on Determining Terminal Status worksheet

Must have either:

  • Symptoms of CHF and /or angina at rest
    • CHF documented by Echo result of < or = to 20
  • Inability to carry out minimal physical activity without dyspnea or angina increasing

OR:

  • Optimally treated with: (or medical reason for not treating)
    • Diuretics, Vasodilators, ACE Inhibitors, Nitrates, PASP (pulm HTN)
    • Other associated medications

Think: Drugs have met their

“Shelf Life” or “Optimal Benefit”

lcd for cardiovascular diseases2
LCD for Cardiovascular Diseases

Review criteria on Determining Terminal Status worksheet

Additional Supporting Data:

  • Treatment resistant symptomatic supraventricular or ventricular arrhythmias (irregular rate or rhythm)
  • History of cardiac arrest or resuscitation (Code Blue)
  • History of unexplained syncope (fainting or passing out)
  • Brain embolism (block by a blood clot, fat globule, air bubble)
  • Secondary Cardiovascular Accident (CVA) of cardiac origin
  • Concomitant HIV disease (happening at the same time)
pulmonary disease
Pulmonary Disease
  • Obstructive Pulmonary Disease
    • Chronic spasm of small airways due to chronic disease
    • 3rd Leading cause of death in U.S.*
      • Lives claimed = 134,676 Americans in 2010
      • 2011, 10.1 million Americans physician diagnosis of Chronic Bronchitis
      • 65 years or > = highest rate of 64.2 per 1,000 persons
      • COPD prevalence = <4% MN & WA vs. >9% AL & KY
      • Pass 11 consecutive years = Women surpassed men in deaths
      • Estimated 715,000 hospital discharges in 2010
      • 2010 Cost of care to nation = approx. $49.9 billion
    • Due to toxin and tobacco exposure
      • Forced Expiratory Volume (FEV1) is reduced <30%
      • Chest is chronically hyper-inflated
        • PaCO2 is incresed:PaO2 drops

(*American Lung Association, 2014)

lcd for pulmonary disease
LCD for Pulmonary Disease

Review criteria on Determining Terminal Status worksheet

Must have:

  • Severe chronic lung disease as documented by disabling dyspnea at rest
    • Poorly responsive or unresponsive to bronchodilators
    • Decreased functional capacity; bed to chair, fatigue, cough
    • FEV1 after bronchodilator <30%
    • Progression as evidenced by
      • Increased ER visits
      • Hospitalizations for pulm infections and/or failure
      • Increased home physician visits
      • Objectively documented with decrease in FEV1 >40ml/year
lcd for pulmonary disease1
LCD for Pulmonary Disease

Review criteria on Determining Terminal Status worksheet

Must have:

  • Hypoxemia at rest on room aire
    • Abnormally low O2 in the blood = shortness of breath (SOB)
    • PaO2 < or = to 55% or O2 saturation < or = to 88% or
    • PaO2 measured by arterial blood gases (ABG) – invasive
    • O2 sat measured by pulse oximeter - non-invasive
  • Hypercapnia with pCO2 > or = to 50 mmHG
    • Increase of carbon monoxide (waste product) in the blood
    • Caused by hypoventilation, measured by ABGs
    • Symptoms: headache, change in LOC, drowsiness, sleepiness
    • Late: flushed skin, dizziness, rapid breathing, increased B/P & HR
    • Late: Respiratory failure and death
neurological conditions
Neurological Conditions
  • 3 Distinct Pathophysiology
    • Injury
      • 3rd Leading Cause of death in U.S.
      • Leading cause of serious long-term disability
    • Trauma
    • Degenerative diseases
neurological conditions1
Neurological Conditions

Degenerative diseases:

  • Dementia
    • Syndrome of acquired and persistent impairment in cognition and intellectual functioning: Irreversible and progressive
    • Characterized by:
      • Intellectual deterioration
      • Disorganization of the personality
      • Inability to carry out the tasks of daily living
      • End Result: Progressive decline in physical and mental function
        • Immobility, debility and death
neurological conditions2
Neurological Conditions

Degenerative diseases:

  • Dementia
    • Alzheimer’s dementia most common in U.S. (50%)
    • Multi-infarct or vascular dementia (20-40%)
    • Other causes of dementia (10-30%)
      • Dementia with Lewy bodies
      • End-stage Parkinson’s disease
      • Fronto-temporal degenerations (including Picks disease)
      • Supranuclear palsy
      • Huntington’s disease
dementia statistics
Dementia Statistics

Prevalence

  • Currently 5.4 million Americans have Alzheimer’s disease
    • May rise to 16 million by 2050 in no breakthrough in preventions or treatment of the disease
  • Disproportionately affects those over age 85
    • Striking between one-third and one-half of this age group
  • Developing a reasonable approach to the medical care of older people with dementia will be essential in the coming decades.
dementia and care
Dementia and Care

Considerations

  • Differs from other diseases such as cancer or heart disease
    • Greater number of individuals affected
    • Decision making capability is affected due to disease progression
    • Prohibits active participation in care planning
  • Incurable, ultimately fatal disease
  • Duration:
    • Some estimates indicate survival is5-10 years
    • Survival from diagnosis to death averages greater than 3 years
  • Does not fit the mold of a typical “terminal illness”
    • Referral to hospice care comes late in illness preventing
    • Prevents optimal opportunity to provide care and support
dementia and acute or chronic illness
Dementia and Acute orChronic Illness

Due to Advanced Age

  • High risk of developing acute and chronic illness
    • Cancer or heart disease, etc.
    • Infections
    • Life-prolonging treatment is often recommended
  • Decisions regarding treatment are necessary
    • Difficult due to changes in mental state due to advancing dementia
    • Necessary to have surrogate decision-maker
dementia and goals for care
Dementia and Goals for Care

Considerations

  • Physician support for acute and chronic illness treatment options
  • Surrogate Decision-maker needed
    • Understanding treatment options and outcomes of care
    • Must uphold patients wishes when they can no longer make their own decisions
    • Quality of Life versus Quantity of Life
    • Benefits of Care versus Burdens
    • Advanced Directives
dementia and hospice
Dementia and Hospice

Comfort as Goal of Care

  • Physician collaboration to implement this goal
  • Goal: “Comfort Care”
    • Preventing suffering
    • Promoting dignity
    • Facilitating caring
    • Psycho-social and spiritual support
  • Referral to hospice care
lcd for neurological conditions
LCD for Neurological Conditions

Review criteria on Determining Terminal Status worksheet

Degenerative diseases:

  • Dementia – Alzheimer’s type

Must have all the following characteristics:

  • Stage 7 FAST Scale
    • Unable to ambulate without assistance
    • Unable to dress without assistance
    • Unable to bathe without assistance
    • Urinary and fecal incontinence
    • No consistent meaningful
lcd for neurological conditions1
LCD for Neurological Conditions

Review criteria on Determining Terminal Status worksheet

Degenerative diseases:

  • Dementia – Alzheimer’s type

Should have had complications within the past 12 months:

  • Aspiration pneumonia
  • Pyelonephritis or other upper UTI or septicemia
  • Decubitus Ulcer, stage 3-4
  • Fever, recurrent after antibiotics
  • 10% weight loss over prior 6 months or albumin < 2.5gm/dl
collaborative success
Collaborative Success

Customer Service Culture

Customer Drive Practices

reflecting

Mission-driven patient-centered culture

Expecting “hospice’s best”

interdisciplinary group meetings idg
Interdisciplinary Group Meetings (IDG)
  • Who?
  • What?
  • When?
  • Where?
  • Why?
  • How?
interdisciplinary group meeting idg
Interdisciplinary Group Meeting (IDG)
  • Who?
  • “Anyone who touches the patient”
  • Individuals working together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patients and families facing terminal illness and bereavement
    • Medical Director, RNCM, Social Worker, Chaplain, Hospice Aide, Volunteer, Dietician, Music, and Massage Therapy
interdisciplinary group meeting idg1
Interdisciplinary Group Meeting (IDG)
  • What?
  • A fluid and interactive process of collaborative communication
  • Facilitated through interdisciplinary group (IDG) meetings
  • IDG members must provide the care and services offered by the hospice
  • The group, in its entirety, must supervise the care and services
interdisciplinary group meeting idg2
Interdisciplinary Group Meeting (IDG)
  • When?
  • Meet no less frequently than every 15 calendar days
  • Purpose: Review of the plan of care
    • Review, revise and document the individualized plan as frequently as the patient's condition requires
    • Revised plan of care must include information from the patient's updated comprehensive assessment and must note the patient's progress toward outcomes and goals specified in the plan of care.

Frequent review improves proactive patient care and outcomes, increasing satisfaction.

interdisciplinary group meetings
Interdisciplinary Group Meetings
  • Where?
    • Hospice office
    • Confidential Space acknowledging HIPAA requirements
    • Not ‘social time’
    • Respect of time and purpose of the meeting
    • But… team collaboration and care plan revisions can happen prior to IDG meetings to ensure best care planning and patient outcomes
interdisciplinary group meeting
Interdisciplinary GroupMeeting
  • Why?
  • Condition of Participation of Medicare Benefit
  • Comprehensive Plan of Care (POC)
    • IDG establishes and follows an individualized written Plan of Care
    • Reflect patient and family goals and interventions based on the problems identified in ongoing assessments
    • POC must include all services necessary for the palliation and management of the terminal illness and related conditions
      • Interventions for Care
      • Frequency of Care
      • Medications, Supplies, DME needs
      • Measurable Outcomes
saint jude hospice
Saint Jude Hospice

Although there may not be a cure,

There can always be healing.

references
References
  • Berry, P. H. (Ed.). (2010). Core curriculum for the generalist hospice and palliative nurse (3rd ed.). Dubuque, IA: Kendall Hunt.
  • Casarett, D. J., & Quill, T. E. (2007). "I'm not ready for hospice": Strategies for timely and effective hospice discussions. Annals of Internal Medicine, 146, 443-449.
  • Gillick, M. R. (2012). Doing the right thing: A geriatrician's perspective on medical care for the person with advanced dementia. Journal of Law,Medicine, and Ethics, Spring, 51-56.
  • Kennedy, J. (2012). Demystifying the role of nurse practitioners in hospice: Nurse practitioners as an integral part of the hospice plan of care. Home Healthcare Nurse, 30, 48-51.
  • WHO. (n.d.). WHO definition of palliative care. Retrieved August 11, 2014, from World Health Organization website: http://www.who.int/cancer/palliative/definition/en/