Sentara Home Health & Hospice Services Greater Peninsula

1. Palliative Care Vs. Curative MedicineSpeaker:Vicki Wilhelm, MDMedical Director, Sentara Hospice for the Greater Peninsula and Western Tidewater Region

2. Sentara Home Health & Hospice Services Greater Peninsula Phone: (757)736-0700Serving Williamsburg, Middle Peninsula and Peninsula Region

3. What is Restorative Medicine? A cross-disciplinary approach for 21st century medicine based on restoring organ function and repairing tissue damage. It is not simply treating symptoms and palliating medical conditions. It combines complementary therapies combined with lifestyle changes with the ultimate goal to prevent future diseases and slow down the progression of existing diseases.

4. Curative Medicine • Seeks a cure for an existent disease or medical condition • Differs from preventive care which aims at preventing the appearance of diseases through immunization, exercise and lifestyle improvements • Differs from symptomatic treatment which is medical therapy of a disease that only affects its symptoms & not it’s causes (ex. Analgesic, anti-inflammatory, antitussives, antihistaminic, etc.)

5. What is Palliative Care? • Interdisciplinary medical care that aims to relieve suffering and improve quality of life for families and patients with advanced illness. • It is offered simultaneously with all other appropriate medical treatment. • Palliate: From the Latin word pallium, meaning cloak • To make less severe or intense

6. Our Definition of Palliative Care Interdisciplinary care that: • Changes the “medical” approach from crisis intervention to crisis prevention through advance care planning and clarity re: the goals of care. • Assesses and works towards the relief of distressing symptoms and improvement of quality of life. • Tends to the whole-person in the context of their family and their community. • Provides access to support for patients and their families at any stage of illness and in any setting, regardless of prognosis.”

7. Palliative care is:It is NOT: evidence-based medical treatment vigorous care of pain and symptoms throughout illness care that patients want at the same time as efforts to cure or prolong life “giving up” provided in place of curative or life-prolonging care the same as hospice the same as comfort care

8. What is Hospice? Hospice is quality, compassionate care for people with life-limiting or life-threatening illness or injury. Care is tailored to each patient’s needs and wishes with the goal being to maximize patients’ quality of life as they travel along this last journey.

9. Why isHospice the Ultimate Gift?

10. Goal of Hospice The goal of hospice is to improve the quality of life and provide comfort and dignity in death. Hospice care neither prolongs life nor hastens death. Hospice focuses on whole person directed treatments with attention to “family” as part of the experience.

11. When to ask for Hospice Services • Early!Crisis avoidance vs. Crisis intervention • A proactive vs. a reactive approach: • more integrated, organized route to wholistic care for a patient and family and • decreases stress and anxiety for all involved.

12. ADMISSION Admission to Hospice requires a Doctor’s order.The Hospice staff can also provide an evaluation for appropriateness of admission to hospice and provide a recommendation back to the provider.

13. Disease Trajectories

14. Disease Trajectories

15. Where does Hospice occur? • At home • Independent or assisted living facilities • Long-term care or skilled care facilities • Hospital • Hospice inpatient units • Hospice House

16. Dispelling Hospice Myths • You do not need to be DNR to enter Hospice • Hospice is not a 24-hour nurse coverage It relies on family and coordinates support including HHA • Hospice patients are offered antibiotics for reversible infections • Medications related to the admitting diagnosis are covered under the Hospice Benefit • Hospice is liberal in its use of Opioids, but only in response to symptom management • Hospice services have been shown to prolong survival and reduce costs at end of life.

17. Interdisciplinary Hospice Team • Patient and family • The patient’s primary physician • Hospice physician • Nurses • Certified nursing assistants • Chaplains • Social workers • Music Care Services

18. The Medicare Hospice Benefit Criteria • Eligible for Part A of Medicare • Terminally ill with a life expectancy of 6 months or less Coverage • Physician services • Medical care through the hospice Medical Director • Case management • Medical appliances and supplies • Medications related to the terminal illness and palliation of symptoms • Speech therapy • Short-term inpatient and respite care • Physical and occupational therapy • Dietary counseling • Homemaker and home health aide services • Counseling and social work services • Spiritual care • Volunteer participation • Bereavement services

19. Prognosis Important factors to consider • Co-morbid illnesses • Rate of decline • Nutritional status • Functional status • Cognitive status • Age and gender • Number of hospitalizations in past year • Will to live • Other (psychosocial, emotional and spiritual)

20. The Prognosis A study in 2000 by Christakis and colleagues [10] found that: • Prognostic accuracy generally erred on the side of optimism. Only 20% of physicians’ prognoses were accurate within 33% of actual survival time • 63% were over-optimistic about life expectancy • 17% underestimated survival time • As the duration of the doctor-patient relationship increased, prognostic accuracy decreased. • In general, there was an 8-fold overestimation of life expectancy for patients who died within 30 days of the prognostic determination. [10] Christakis NA, Lamont EB, BMJ 2000;320:469-472

21. Medicare Hospice Benefit Eligibility • Patients must be eligible for Medicare Part A, and • The patient’s doctor and hospice medical director certify that s/he may have six months or less to live if their illness runs its normal course, and • Patient chooses a Medicare approved Hospice program, and • Patient signs a statement choosing hospice care instead of other Medicare-covered treatment options

22. What does Medicare pay for? • Physician and Nurse Services • Medical Equipment • Medical Supplies • Medications for pain and symptom management • Health Aide Services • Social Worker Services

23. Additional Medicare coverage • Physical and Occupational Therapy • Speech Therapy • Dietary Counseling • Short Term In-Patient Care • Grief and Loss Counseling for patient and for patient’s family • Short Term Respite Care (small co-pay applies)

24. A patient can continue to qualify for hospice if they are showing documented signs of decline and at the time of recertification they still appear to have less than six months of life expectancy.

25. Hospice Medicare benefitdoes not cover: • Treatment intended to cure terminal illness • Prescription drugs to cure illness rather than for symptom control or pain relief • Room and board • Care from providers not arranged by the hospice team, including • Emergency Room care • Inpatient facility care • Ambulance transportation

26. Important Reminder… Medicare will still pay for covered benefits for any health problems that are not related to the terminal illness.

27. Timing of Referrals to Hospice and Palliative Care is Late • Median length of stay in hospice = 10 days • 42% of hospice patients receive care for < 1 week before death • 4.8% 180 days or more • Median LOS in hospitals before palliative care consultation = 18 days (CDC Nat’l Center for Health Statistics 2004) www.nhpco.org & Mount Sinai Hospital Palliative Care Consult Service data CDC National Center for Health Statistics 2004

28. Does hospice provide help to the family after the patient dies? Yes, hospice provides continued contact and support for family and friends for a minimum of 13 months following the death of a loved one. Team members of Sentara Hospice include professional chaplains and counselors specifically trained to provide bereavement support.

29. Why does it take several doctors to treat a patient but only 1 nurse?

30. Sentara Home Care &Hospice Services 200 Enterprise DriveNewport News, VA 23603 Phone: (757) 736-0700Fax: (757) 969-6610

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