Special Interventions

[aimeee, BSN, RN]

I thought this was interesting. Which of these interventions does your hospice cover and under what circumstances?

Title: Fast Fact and Concept #90: Medicare Hospice Benefit Part III: Special Interventions

Author(s): Robin Turner, MD

This fast fact will discuss the use of interventions in hospice care that are often controversial and confusing. When a patient elects the Medicare Hospice Benefit (MHB), the patient, the doctor and the Hospice team develop a Plan of Care (POC) that lists a) the patient?s goals for care and b) the services needed to achieve these goals. A hospice program is fiscally responsible for all services (no copay except $5 for meds) outlined in the POC either directly, or through contracts with approved providers (e.g. contract with local hospital for radiotherapy). All hospice services and contracted arrangements are paid from the pool of money the hospice program gets from the per diem payment (see Fast Facts # 82, 87).

Note: since there is no Medicare regulation that specifies what treatments are deemed palliative, it is up to the individual hospice agency to determine whether or not they can financially and philosophically provide the interventions listed below. These interventions range from low cost-low tech (hydration via clysis) to high cost-high tech (multi-agent chemotherapy). With the exception of very large hospice agencies that have a substantial financial base, most agencies will not provide high-cost interventions; patients may elect to be discharged from hospice care if they wish to pursue these options.

Indications for use in Hospice Care In general, the interventions listed below are potentially indicated in patients with a) good functional status (up, out of bed > 50% of the time; KPS >50; ECOG 0-2) and/or b) a clear goal to be met (e.g. wedding anniversary in two weeks). These interventions are not indicated solely to assist patients or families psychologically cope with impending death -- to give the impression that ?something? is being done.

Parenteral Fluids Indication: symptomatic dehydration where there is a patient-defined goal (e.g. upcoming family event). Fluids are not indicated to treat dry mouth or solely to reverse dehydration occurring as a normal aspect of the dying process; fluids may be of benefit to treat delirium in selected patients.

Enteral feeding Indication: patient is hungry and there is a reason oral nutrition can?t be given (e.g. GI obstruction from esophageal cancer). See Fast Facts #10 and 84 for complete review and indications/contraindications for tube feeding.

Radiation Therapy Indication: symptom of pain, bleeding or neurologic catastrophe (e.g. acute spinal cord compression) and the patient is expected to live long enough to experience benefit (> 4 weeks) and the potential benefits outweigh logistic burdens (e.g. travel to the XRT site, getting on and off the treatment table). See Fast Facts # 66, 67.

Red Blood Cell Transfusions or Erythropoietin Indication: Symptomatic anemia (dyspnea or fatigue) in ambulatory patients who demonstrate continued functional benefit.

Platelet Transfusions Indication: active bleeding and severe thrombocytopenia (Plt Count

Chemotherapy Indication: symptoms from the cancer causing distress and likelihood of effectiveness is high (expected Response Rate greater than 25%--see Fast Fact #14) and patient will live long enough to benefit (> 4-8 weeks) and benefit outweighs burden and the patient is ambulatory (ECOG 0-1).

Antibiotics Indication: Oral antibiotics are appropriate to treat simple symptomatic infections (e.g. UTI). Parenteral antibiotics are not indicated unless there is an identified susceptible organism, and there is a clear functional goal to be met and the likelihood of successful treatment is high and the patient is expected to live long enough to achieve benefit.

Total Parenteral Nutrition Indication: TPN is appropriate in hospice when caring for a patient with short-gut syndrome or bowel obstruction and good functional status and a functional goal.

Laboratory/Diagnostic services Indication: to monitor aspects of POC (e.g. warfarin monitoring). Note: Diagnosis of a new problem that does not relate to the terminal illness can be evaluated and treated by the patients primary care provider under usual Medicare (e.g. AMI).

References Standards of Practice for Hospice Programs. The National Hospice and Palliative Care Organization. 2000. Hospice Manual. Chapter II-Coverage of Services. Online: http://cms.hhs.gov/manuals/21_hospice/hs200.asp.

[renerian, BSN, RN]

Aimee it would take me forever to address all those issues. I hope someone has time to. I am just swamped and cannot.

renerian

[aimeee, BSN, RN]

Well, it won't take me long because the only one we ever cover is the IV fluids! We don't often do that. I wish we could afford to cover more. Things like Procrit and Aranesp are real stumbling blocks for us. We just had to postpone a referral last week because the patient wanted to keep getting her Aranesp.

[NRSKarenRN, BSN, RN]

Had an interesting Hospice referral last week.

Pt on Hospice due to End stage Cardiac diseas--she tripped and fell, fx femur and admitted to hospital not under Hospice benefit. They requested we provide PT under MC home care benefit---found out we could using special billing code.

Five days later, family decided to cancel hospice and convert all services to homecare so we can maximize her walking.

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When I worked Hospice 91-93 we provided:

1. TPN only in GI severe malaborption/obstruction + when pt not ready to give up on food idea---rarely used.

2. No IV hydration----TONS of Enure supplement freely provided + by volunteer's.

3. Oral analgesics preferred route, then Duragesic, last IV MSO4/Dilaudid for severe pain management.

4. No Chemo or blood products. Epogen for those with long standing anemia and ambulatory--- many pts declined over course of tx.

5. PO Antibiotics only ---at patients discression.

6. Radation therapy as part of pathological fx tx for pain refief and in spinal cord compression---used occationally.

7. Rarely did labs--mostly PT/INR and that was usually NOT under hospice benefit.

Hope that helps.

[Wren]

Aimeee,

My experience almost exactly mirrors Nrs. Karen....

Pain Mgmt started oral then with some pr or transdermal and then a fair number of patients on MS04 via pca sc pump. Rarely IV pain mgmt...to hard to keep intact site.

Radiation infrequently and then only for pain mgmt or spinal cord compression.

Antibiotics were used occasionally.

Rarely did labs and like Karen, generally not under Hospice benefit

Had a few with chemo but only folks with private insurance and hospice benefit where the insurer paid for the chemo and let the person stay on hospice.

I never had anyone on TPN and never had anyone on IV fluids (except in a nursing home) and that was very infrequent.

[kids]

Question:

What happens if the patient requests (an expensive but) covered treatment? What if there is no clear benefit to the patient (other than possibly prolonging their death)?

[aimeee, BSN, RN]

Well....its always difficult to speak in generalities because these are the sort of cases where all the little details get fed in to weigh out where it falls in the policy decision. If there is no clear benefit, then I would say we would probably not regard it as truly palliative, and so it would NOT be covered. If the patient/family are not yet in a place where they give up the measures which are life prolonging, but not palliative, then they usually either remain with homecare or we take them on with supportive care.

(Supportive care meaning we provide them with all the personnel services....nursing/psychosocial/spiritual...provided free of charge...and their insurance/medicare/medicaid remains available to pay for the costly treatment.)

[Agnus]

Generally our hospice considers ABX as curative and therefore not an acceptable hospice Tx. I saw ABX once that was when a course had been started already and not completing the 10 day course. So they "allowed" it. However they would not allow a renewal of the order for any additional doses.