Board Review Hospice and Palliative Care

1. Board ReviewHospice and Palliative Care Susana A. Alfonso, M.D. Assistant Professor Emory Department of Family and Preventive Medicine June, 2008

2. Question #25 25. An 85-year-old female with hypertension is receiving hospice care for oral cancer. Which one of the following services typically would NOT be covered under hospice? • Dietary counseling • Short term inpatient care • Drugs for symptom control • Drugs for hypertension • Speech therapy

3. Hospice—What is it?? • A philosophy…not a place • Dying patients have physiologic, psychological, social, and spiritual aspects of suffering • Multidisciplinary team to support PCP to include chaplain, social worker, therapist etc

4. Hospice—Who Should Be Considered?? • Patients with a terminal illness whose prognosis is less than 6 months • 56% of hospice admissions have non-cancer diagnosis (CHF, COPD, Failure to thrive, dementia)

5. Clinical Indicators • Cancer Carcinomatous meningitis Distant metastases Malignant complication such as bowel obstruction, pericardial effusion, or hypercalcemia Multiple tumor sites (>= 5) • Chronic obstructive pulmonary disease Chronic hypercapnia: Paco2 > 50 mm Hg Corpulmonale Dyspnea at rest, persistent resting tachycardia Intensive care unit admission for exacerbation New dependence in two activities of daily living • Congestive heart failure New York Heart Association class III or IV with symptoms despite maximal medical management Serum sodium level < 134 mEq per L (134 mmol per L), or creatinine > 2.0 mg per dL (180 µmol per L), attributable to poor cardiac output

6. Clinical Indicators • Dementia Acute hospitalization (especially for pneumonia or hip fractures) Dependence in all activities of daily living, language limited to several words, inability to ambulate • General decline (failure to thrive) Dependence in most activities of daily living Frequent hospitalizations, office or emergency department visits Weight loss > 10 percent over past six months

7. Medicare Eligibility • The patient is eligible for Medicare Part A (hospital insurance) • The patient is enrolled in a Medicare-approved hospice • The patient has signed a statement choosing hospice • Both the patient's physician and the hospice medical director certify that the patient has a terminal illness with an estimated life expectancy of less than six months

8. Medicare Criteria • Progressive disease with increasing symptoms and/or worsening lab values and/or decreasing functional status and/or evidence of metastatic disease, particularly brain. • Stage IV at initial diagnosis; Stage III with pleural effusion; or State II with patient continuing to decline despite definitive therapy • Karnofsky Performance Status < 70 or Palliative Performance Score < 70% • Symptomology: • Pain • Dyspnea • Significant hemoptysis • Superior vena cava syndrome • Lymphangitic lung involvement • Recurrent pneumonia (two or more episodes in three months)

9. Medicare Criteria-cont • Laboratory abnormalities: • LDH > twice normal • Albumen < 2.5 • Calcium > 14 • Weight loss of five percent or more in the last three months due to progressive disease, or irreversible dysphagia or loss of appetite; • Presence of severe co-morbidities that contribute to a life expectancy of six months or less, including but not limited to: • Chronic obstructive pulmonary disease • Congestive heart failure • Diabetes mellitus • Neurologic disease (CVA, ALS, MS) • Renal failure • Liver disease • Acquired immune deficiency syndrome (AIDS) • Dementia • Recurrent disease after surgery/radiation/chemotherapy.

10. Examples of Disease States Advanced end stage senescence or debilityAmyotrophic lateral sclerosis (ALS)CancerCardiovascular diseaseEnd-stage dementiaFailure to thrive

11. Disease States--cont HIV diseaseLiver diseaseMultiple sclerosisNeuromuscular diseaseOncologyParkinsons diseasePulmonary diseaseRenal disease

12. Recommendations from AAFP • Patients with cancer and non-cancer diagnoses benefit from hospice services and should be referred when their prognosis is still longer than two months. B • Discussions with patients and families about hospice should take place as early as possible and should be approached in the context of the larger goals of care. C Eleven to 18 percent of families feel they were referred too late; late referrals are associated with decreased family satisfaction with services and increased caregiver morbidity • When a patient has NYHA class IV heart failure and is symptomatic despite optimal medication management, a hospice referral is appropriate. C • When a patient who has dementia is dependent in all activities of daily living and cannot communicate, a hospice referral is appropriate. C

13. Common Misconceptions • Patients will be discharged from hospice if they do not die within six months There used to be a six-month regulation that penalized hospices and patients when a patient lived too long, but it was revised and there is no longer any penalty for an incorrect prognosis if the disease runs its normal course • Patients in hospice must have a DNR order Medicare does not require a DNR order to enroll in hospice, but it does require that patients pursue palliative, not curative, treatment; individual hospice organizations may require a DNR order before enrolling a patient • Patients in hospice must have a primary caregiver Medicare does not require a primary caregiver, but this may be a requirement of some hospice organizations • The primary physician must transfer control of his or her patients to hospice Most hospice organizations encourage primary physician involvement; the primary physician becomes a part of the team and contributes to the hospice plan of care • Only patients with cancer are appropriate candidates for hospice Anyone with a life expectancy of less than six months and who chooses a palliative care approach is appropriate for hospice*

14. Common Misconceptions--cont • Only Medicare-eligible patients may enroll in hospice Most commercial insurance companies have benefits that mimic the Medicare Hospice Benefit; individual hospices vary in their willingness to take uninsured patients • Patients in nursing homes are not eligible for hospice This was once true, but Medicare now covers patients in nursing homes • Patients are not eligible for hospice again if they revoke the hospice benefits Patients who want to return to hospice care can be readmitted as long as hospice conditions of participation are met • Only physicians can refer patients to hospice Anyone (e.g., nurse, social worker, family member, friend) can refer a patient to hospice

15. Common Misconceptions--cont • Hospice care precludes patients from being able to receive chemotherapy, blood transfusions, or radiation Medicare requires that hospice must cover all care related to the terminal illness; individual hospice agencies are allowed to determine whether a specific treatment is palliative (providing symptom relief), which will guide what treatments they are willing to cover • Patients who have elected the hospice benefit can no longer access other health insurance benefits Each insurer has rules defining eligibility for covered services; medical problems unrelated to the terminal illness continue to be covered under regular Medicare insurance • Patients in hospice cannot be admitted to the hospital While the patient is enrolled in hospice, most insurance companies, including Medicare, will still cover hospital admissions for unrelated illnesses, as well as for the management of symptoms related to the terminal diagnosis, and respite care • Hospice care ends when a patient dies All hospice programs must provide families with bereavement support for up to one year following the death of the patient

16. Physician Barriers to Referrals • Negative perceptions about hospice • Discomfort communicating terminal diagnoses and prognosis • Inability to identify an appropriate diagnosis • Fear of losing control of the patient • Overestimation of life expectancy

17. Tools for Determining Prognosis in Terminally Ill Patients • Karnofsky Performance Scale • National Hospice Organization Medical Guidelines for Determining Prognosis in Selected Non-Cancer Diseases • Palliative Performance Scale • Palliative Prognosis Score • National Hospice and Palliative Care Organization (http://nhpco.org) note: See also the AFP Point-of-Care Guide on Determining Prognosis for Patients with Terminal Cancer, at: http://www.aafp.org/afp/20050815/poc.html.

18. Hospice Expectations for Attending Physicians • Maintain primary responsibility for the patient • Write basic admission orders • Work in collaboration with the hospice team to manage symptoms • Provide prescriptions and medication refills as needed • Continue to certify that a patient remains eligible for hospice • Complete and sign death certificate

19. Practice Management Considerations: Billing • Physician can bill for non face to face time • Services provided by non-physician ie PA • 15-30 minutes per month of cumulative service (phone, coordination of care, records review) • Has to have signed original certification • Cannot be an employee of hospice

20. When should you discuss this with your patients??? • BEFORE THEY GET SICK • Fastest growing segment of the population…85 years and older • Live 30 months after a diagnosis of terminal illness

21. Initiating Hospice Conversation • Redirection of Goals from Cure to palliation • Witness of Events • Healing of Relationships

22. Tips for Any Difficult Conversation • Make time, place, and eliminate distractions • Find out what the patient knows • Find out what the patient wants to know • Listen with your ears, eyes, and heart

23. CME QUIZ 5. A hospice referral for an 82-year-old nursing home patient with prostate cancer is most appropriate in the presence of which one of the following factors? A. The patient's tumor is localized. B. The patient's Karnofsky score is greater than 50. C. The patient has a malignant pericardial effusion. D. There has been no documented change in the patient's activities of daily living.

24. CME Quiz Which of the following statements about the physician's care of a patient in hospice is/are correct? A. The physician can fax narcotics prescriptions to the pharmacy. B. The physician needs to approve the recertification of the patient after the first 90 days. C. For billing purposes through Medicare Part B, the physician needs to visit the patient at least once every six months. D. The physician can bill through Medicare Part B for calls made by his or her physician's assistant.

25. CME Quiz-FPM 1. What is the best time for a physician to discuss advance directives with a patient, according to the article? A. Before the patient turns 50 years of age. B. When the patient has been admitted to the hospital. C. Before the patient approaches the end-of-life stages. D. When the patient has been diagnosed with a terminal illness. E. When the patient enters hospice.

26. CME Quiz-FPM 10. Which of the following should physicians consult when predicting life expectancy, according to the article? A. The Palliative Performance Scale, or similar tools. B. Another physician. C. The patient's family. D. Key clinical indicators such as weight loss or recurrent infections

27. REFERENCES • Old, Jerry L. Discussing End-of-Life Care with Your Patients. Family Practice Management 2008; March: 18-28. • Weckmann, Michelle T. The Role of the Family Physician in the Referral and Management of Hospice Patients. American Family Physician 2008; 77(6): 807-816.