Seema S. Limaye, MD University of Chicago

1. Mini-CHAMPPart I: Hospice and Palliative Care--the Idea & the Medicare BenefitPart II: Teaching how to “Break Bad News” Seema S. Limaye, MD University of Chicago

2. Part I: Hospice and Palliative Care--the Idea & the Medicare Benefit.Part II: Teaching how to “Break Bad News”. Section of Geriatrics September 8, 2008 Mini-CHAMP Lecture Series

3. Goals • Understand hospice and palliative care services and the Medicare benefit. • Identify older adult patients for whom hospice care is appropriate. • Discuss hospice care with older adult patients and their families. • Teach effective communication skills to medical students and residents to run family meetings

4. Hospice focus is on pain and symptoms management patient has a terminal diagnosis with life expectancy of less than six months not seeking curative treatment Palliative Care focus is on pain and symptom management patient does not have to be terminal may still be seeking aggressive treatment Comparing Hospice vs. Palliative Care

5. How are hospice and palliative care similar? • Focus is on quality of life of the patient. • The goal for both types of care is to address any adjustment to illness or end-of-life issues.

6. Medicare Hospice Benefit • To receive this benefit package, a patient needs to sign up – designating all of their Part A benefits involving care related to their primary terminal diagnosis over to the hospice agency

7. What is included in this benefit • The hospice team – RNs, SW, chaplain, supervision of a hospice physician, Nurses Aids up to 1-2hrs daily, volunteers (usually 3 hrs a wk), and bereavement support for up to 13 months after • Medications/therapies for the sole purpose of palliation of symptoms related to the primary diagnosis • Medical equipment for safety/symptom relief • Dressings/other care needs related to the diagnosis • 24 hr coverage

8. Where can hospice be practiced? • Remember, hospice is a philosophy—to provide dignity and comfort when the patient has a terminal diagnosis(es). • Home • NH • Hospice houses • Inpatient hospice units

9. Various levels of care • Routine home care/nursing home at intermediate nursing level • Respite care – up to 5 days a month rest for family, with patient in a nursing home – room and board and cared paid by the hospice • Continuous Care – 8 – 24 hrs of care a day, 50% of which is done by an RN/LPN, only available with a skilled need – aggressive symptom control, acute agitated state, rapid physical change. The need is evaluated daily

10. Various levels of care (cont) • In-patient Hospice – For patients who need aggressive symptom relief requiring continuous monitoring. • This is usually only for up to 5-7 days. • If patient stabilizes, a new setting needs to be found. • The cost of this is paid by the hospice via Medicare

11. Do patients/families give up by signing the benefit? • While in hospice it is very difficult to do aggressive life-prolonging care; but we do aggressive comfort care! • They can always sign out of the benefit anytime to pursue more life-prolonging care, without penalties • They can continue to see their doctors • Medicare will pay for secondary diagnoses care, i.e.: dialysis for long-standing renal failure • You cannot be in a SNF for rehab and in hospice at the same time

12. What about other insurances? • Medicaid follows Medicare protocols; reimbursement is similar • Private insurances/HMOs have a huge range depending on each individual plan – from NO hospice coverage, to a $3000 limit (about 20 days), for a full coverage with unlimited in-patient stay and more aggressive treatment plans paid for separately

13. Common Hospice Misconceptions • The patient must be bedridden in order to be eligible for hospice care. • Hospice promotes QOL and function! • The patient must have cancer. • Being on hospice means giving up hope. • Help patients and families re-frame their hope.

14. Common Hospice Misconceptions (cont) 4. I need to be “DNR” to sign-up for hospice. 5. I lose control/access to medical care if I sign-up for hospice. 6. I cannot dis-enroll from hospice if I change my mind or get better. 7. It’s “too early” for me to sign-up for hospice. -If patient is medically appropriate for hospice, focus on the extra support they will receive at home, and improved quality of life because of symptom control.

15. So who should get palliative care services? • Patients with symptoms related to chronic illnesses who may still be seeking aggressive treatment. • The focus is on pain and non-pain symptom management. • Initiate conversations about patients’ goals of care, understanding these may changes as disease progresses/remits.

16. In-home palliative care increased patient satisfaction and reduced use and costs of medical services Design: Randomized, blinded controlled trial. Follow-up period: Death or end of study period. Setting: 2 HMOs in Hawaii and Colorado, USA. Patients: 310 patients (mean age 74 y, 51% men) who had a primary diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or cancer; had a life expectancy  < 12 months; had visited the emergency department or hospital within the previous year; and scored  70% on the Palliative Performance Scale. Brumley R. et al.Increased Satisfaction with care and lowered costs: results of a randomized trial of in-home palliative care. JAGS; 2007;55;993-1000.

17. IHPC Study • Intervention: IHPC plus usual care (n = 155) or usual care alone (n = 155). • Physicians conducted home visits and were available, along with nursing services, on a 24-hour on-call basis. • Usual care: followed Medicare guidelines for home health care criteria to provide various amounts and levels of home health services, acute care services, primary care services, and hospice care.

18. Outcomes/Results • Pt Satisfaction: IHPC better than UC at 30 and 90 Days (93% vs. 80%) • Cost: IHCP cheaper than UC ($12,670 vs. $20,222) • ER visits: IHPC vs. UC (20% vs. 33%) • Hospital Admissions: IHPC vs. UC (36% vs. 51%) • Death at home: IHPC vs. UC (71% vs 51%) • Life expectancy: IHPC vs. UC (196days vs. 242 days)

19. Palliative Care Services Offered at Home • Initially, a physician or APN visits the patient at home to assess symptom control and goals of care. • Patient is evaluated about every 2 weeks for symptom management. • Interdisciplinary Pall Care team: may include SW, chaplain, APN, MD to see Pt as needed. • Pall care team can help transition patients to hospice if disease progresses, goals of care change. • Extra home nursing or CNA services provided on sliding scale fee-for service.

20. Continuum of Care Bereavement Care Hospice Disease modifying medical therapy *Curative, life-prolonging, or palliative in intent Palliative Care *Symptom control, supportive care Illness Death

21. Palliative Care Reimbursement • There is no reimbursement directed to this yet • Right now, only the physician or advanced nurse practitioners billing under their usual specialty for symptom diagnosis is reimbursed. • Rest of care is billed under their usual Medicare/insurance – i.e.: part D for meds, home care for aids/RNs • Some hospitals do their in-patient care under this, billing for the DRG for the diagnosis outside of hospice

22. Communicating Bad News • Not widely taught in medical education. • Learners often cite observation as only prior experience they get before having to “break bad news” on their own. • Currently 3rd year Pritzker students have 1.5hr workshop to learn how to break bad news.

23. Challenge • So how do we teach these important communication skills considering the time-crunch we all face? • PRACTICE! • Devise “game plan” before the meeting: teach the SPIKES mnuemonic • Supervise initial family meeting

24. 6 Steps/”SPIKES” • Set up the interview • Find out what the patient knows (Perception) • Find out what the patient wants to know (Invitation) • Give information (Knowledge) • Respond to the patient’s emotion (Emotion) • Closing (Summarize/Support) Baile WF. Buckman R. Lenzi R. Glober G. Beale EA. Kudelka AP. SPIKES-A Six Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist 2000;5;302-311.

25. 1. Setting • Prepare yourself (grooming, data, pager…) • Prepare the room (privacy, chairs, tissues) • Gather others patient might want there • Make eye contact • Appropriate body language • Adequate amount of time

26. 2. Perception • “What is your understanding of what is going on currently with your medical situation?” • Knowing patient’s level of comprehension enables you to start at appropriate point. • Can abort process if it appears more is needed (family members, other support).

27. 2. Perception, cont’d. • Language Barriers: • Use a medical interpreter, NOT family • Speak to the patient

28. 3. Invitation • “If the results of your tests were serious, do you want us to talk with you alone, or are there others you would want present?” • “How much of your medical condition do you want to discuss?”

29. 3. Invitation, cont’d. • What if family asks you not to discuss findings with the patient? • Ethically & legally obligated to discuss with patient what they want to know, and who else they want info discussed with. • Best to do this in front of family.

30. 4. Knowledge • Give warning shot! • Use language the patient will understand (no medical lingo). • Stop frequently to check for understanding (“Is what I am saying making sense?”). • Small amounts of information at a time. • Allow for silence! • Use appropriate body language, eye contact. • Avoid vague terms (“tumor”, “mass”, “abnormality”)

31. 4. Knowledge, cont’d • What if they ask for prognosis? • ONLY answer if you are comfortable/reasonably sure; otherwise, say “I really cannot say at this time.” • Answer only in categories: hours to days, days to weeks, weeks to months, months to years (“…if the disease progresses the way it usually does in these situations…”)

32. 5. Emotions • Acknowledge reactions, but don’t assume feeling. (“It is ok to cry. I realize this must be very upsetting to you.”) • Normal: tears, anger, anxiety, denial, blame, guilt, fear, shame • Consider using silence, touch.

33. 6. Summary • Summarize what you have told the patient. • Establish what the next immediate steps should/could be. • Ask patient if s/he has more questions. • May need to return very soon (patient may want other family members, may want time to process).

34. Common Medical Student Concerns/Barriers to Effective Family Meetings • “ I was sent in to deliver bad news without being prepared.” • “I didn’t know how to answer certain questions about prognosis” • “The family did not want the Patient to know about the diagnosis or prognosis.”

35. Effective Strategies • BE HONEST—”They had a lot questions I could not answer.” • ASK THE EXPERTS--“The family had a lot of questions after the initial meeting. I sat down with them and came up with a list of questions for the oncologist and surgeon.” • COMMUNICATE DIRECTLY WITH THE PATIENT, IF POSSIBLE—”How much do you want to know about your medical condition?”

36. Goals • Understand hospice and palliative care services and the Medicare benefit. • Identify older adult patients for whom hospice care is appropriate. • Discuss hospice care with older adult patients and their families. • Teach effective communication skills to medical students and residents to run family meetings

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