Appropriate for Hospice?

I've seen many of patients that were not appropriate. I knew upon admission that this person was going to outlive the Hospice time period. On the flip side, they said, just do what we tell you to do..Ok, so I go, do what is told, report my findings every visit, then Whammo....they get surveyed and have to pay back all that money they charged Medi'cal/care for. I do believe admissions are done to keep doors open, but in reality doors close and people are out of jobs, such as I.

I had a pt. for 2 years with "End Stage Parkinsons disease", during that period, she never ever declined one bit, stayed the same, but the daughter kept "looking for ways to keep hospice" and Hospice kept looking for ways to keep her, like uti..come on, a uti is NOT a hospice dx...among other things.

The criteria for hospice is that two physicians must cerify that if the condition runs its normal course they estimate a six month or less prognosis for the patient. In addition, there are disease specific guideline, called LCDs, that can be used to qualify the patients terminal status.

Here is a link to get an idea of what I am talking about

http://www.cms.gov/mcd/viewlcd.asp?lcd_id=13653&lcd_version=29&show=all

I was seeing a pt at our inpt center for education regarding his tube feeds through a replaced g-tube. He will go home with Hospice visiting and providing further education. His diagnosis is esophageal CA so I'm not sure about his prognosis. He's A&O x 3, ambulates, no real pain issues. I'm sure he's appropriate, I just don't see him passing soon. Also, our doc is ordering more iv pushes and fluids, so we'll be starting iv's/heplocks to give the meds. Just seems weird to me that we're having more pts admitted that do not always seem appropriate. I know its related to medicare cutbacks and keeping census up to keep our doors open. I don't know, seems like we're doing more outside the realm of Hospice. How about everyone else? I believe in the Hospice philosophy but it seems different with new regs.

So the kicker is this...you don't envision him dying "soon" but what does that mean? Do you think that he will likely live more than 6 months? It requires the opinion of 2 physicians that the expected life span is 6 months so... Personally, I love it when we get patients who are not a death's doorstep. It allows us the luxury of time to develop the important hospice relationships. It allows us to actually help the patient and family to enjoy quality of life before we help them have a comfortable death...that is part of the pay back for us...

Geez...on another note...I hate when Esoph Ca patients have Gtubes, etc. They generally are so sick, so nauseated, and so sad at the end of their lives because their families want to keep putting food in the tube...

The last guy I took care of (59 yr) told me he was so sorry he had it placed and if he could do it over he would never agree to insertion. In his particular case, he was plagued with nausea and vomiting the entire duration of his life with the tube...in short, he was miserable. Ahhh, if only we had crystal balls...

Our company calls it the "Open Access" approach.

The money people here say that the company loses money for the first and last weeks of a client's life ... it's the time between, when the client is on routine home care and relatively stable, that the company is best able to meet the client's needs and still keep costs below the reimbursement rate. Therefore, it pays to sign on clients as early in the terminal disease process as possible.

The hospice time period is not written in stone ... that's what the re-certification process is about ... to document continued eligibility for hospice.

Some of our patients ... mostly end-stage COPD, I hear ... stay on service for as long as a couple of years.

Although I know that this "Open Access" approach is purely business (although it is described in marketing materials as a compassionate concern for all those who need hospice care) ... I happen to agree with it. There is seldom a point in a final illness when all treatment stops and comfort measures only start ... it's a progression as the patient, family and providers move through various treatment options, then to maintenance care, then to comfort care only.

Traditional hospice has always been primarily involved in the comfort care only piece ... and it was this time of life that the Medicare hospice benefit was designed to support.

This leaves the time between when curative care stops but maintenance care continues ... some call it palliative care, as opposed to hospice care which focuses on the final decline. It's the patients in this palliative/maintenance phase that the companies are trying to attract. They have a documented life-limiting illness, they have stopped aggressive curative treatment, but they ain't dead yet. By it's nature, palliative care is more aggressive than comfort care only ... thus the iv meds, feedings, antibiotics, etc. that we all struggle with.

I happen to think that hospice providers are uniquely suited to provide this palliative care and patients/families going through this certainly need the support. (See tewdles' post above).

What I haven't figured out is how a revenue stream (the Medicare hospice benefit) designed to fund low-cost comfort care in the home is supposed to stretch to pay for more aggressive palliative care and still turn a profit. I think this is where business ethics and our documentation of ongoing decline come into play. We have to keep asking questions like those in the OP.

Even our non-profits have to turn a profit ... none of us works for free ... and who's gonna give the care if all the providers are bankrupt? It's a hard one.

For the hospice agency I work for, hospice services are appropriate for any person who has been given a prognosis of 6 months or less to live. Most of our clients don't live the full 6 months on hospice care, but that is usually because the average pt signs up with us for 14-21 days before death. This is a testiment to the general public not really understanding the philosophy of hospice. It is our goal to begin hospice care as soon as possible, and not wait until symptoms are so great (or death is imminent) to start comfort measures. Our agency has found that often times, the ealier the pt is provided with comfort care, the better the quality of their life...and in some cases it even extends it.

In terms of hospice diagnoses, no one can really predict when someone is going to die. Just because a doctor says 6 months, there is no guarentee. If the pt who has been on hospice shows no decline, then we put them on a "stable status" program, where we continue to follow them, but they are no longer under the medicare benefit for hospice. When hospice pts are re-evaluated, what we look for are signs of decline. This does not always mean the development of severe conditions, but normal signs that are indicative of disease progression. The real cost of our services are very low...and are by FAR less expensive than continuing agressive treatments that ruin quality of life and often provide a false sense of hope. This can also amplify negative feeling families and loved ones harbor when they lose someone.

Honestly, people should stop looking at hospice as only a term that applies to pain, suffering, and death. When a pt has a terminal prognosis, it is so important that hospice teams come in and work with pts and families on what to expect, how best to treat symptoms, support systems, legacy work, and to know that there are people who care.

That is part of our job, Sterling, to educate the public one family, one person at a time.

lesrn, do not underestimate the rancor of any cancer.

i've had soooo many ca pts who 'appeared' stable, only to crash in a moment's notice.

esophageal ca is an aggressive, nasty cancer, and feel safe in stating your pt is likely very appropriate for hospice care.

take advantage of his current viability, and make the most of his life.

when he deteriorates, then make the most of his dying.

that's what we do.

leslie

I agree with all posters, we educate and treat. Hopefully to give quality vs quantity. I/we do not try to end life in any way, Life is allowed to take its natural course. However, when you have management say

1. "find something to keep him/her on".....what do you do?

2. When the Patient and Family are ACTIVELY seeking curative treatment for Parkinson's, paying for it out of their own pocket, its a bit difficult to document.

3. thanks for the link loricatus...I am familiar with, but will keep it saved for ref!

I agree with all posters, we educate and treat. Hopefully to give quality vs quantity. I/we do not try to end life in any way, Life is allowed to take its natural course. However, when you have management say

1. "find something to keep him/her on".....what do you do?

2. When the Patient and Family are ACTIVELY seeking curative treatment for Parkinson's, paying for it out of their own pocket, its a bit difficult to document.

3. thanks for the link loricatus...I am familiar with, but will keep it saved for ref!

I, fortunately, have not ever worked for a hospice which asked me to "find something to keep him/her on". The hospices that I have worked for are diligent about discharging people who no longer meet eligibility. The administrative team I currently work for appreciate clinical staff who are proactive in their assessments and recommend discharge when patients are not demonstrating decline in health status/functions, particularly in elderly dementia or cardiac failure patients.

In my area, pursuit of curative treatment for the hospice diagnosis is grounds for discharge...even if the family is paying out of pocket...those goals are not typically compatible with hospice goals.