Many have expressed concern about the very short stay of patients in hospice, resulting in the difficulty to provide all the available benefits at end of life. These short-stay patients are a result of their physician's reluctance to have "the conversation" about end-of-life planning. The result of this delay is that patients and families are sometimes unwilling to accept a terminal prognosis and the incentives of the Medicare fee-for-service system (MedPac, 2013).
The costs of hospital care during the final years of life are high. According to a 2012 report from the Agency for Healthcare Research and Quality (AHRQ), 5% of the population accounts for nearly 50% of spending (Cohen et al., 2012). A disproportionately large percentage of resources are spent on patient care in the last 2 years of life, much of it unwanted by patients, unnecessary, and ineffectual in prolonging life. A recent study by Joan Teno indicated that although death in hospitals has decreased to 25%, the percentage of people in the ICU in the last month of life increased to 29% in 2009 (Medicare Newsgroup, 2013).
In 2011, 10% of all Medicare patients entering hospice had a length of stay (LOS) of 2 to 3 days and 25% of patients had a LOS of 7 days or less regardless of diagnosis (MedPac, 2013). According to MedPac, costs are higher at the beginning and end of care, which, for short-stay patients, includes both of these time frames (MedPac, 2013). Due to the intensity of hospice services, MedPac has made recommendations to align reimbursement to costs (MedPac, 2013).
Cost is a significant concern for hospice short-stay patients, but equally important are the quality issues. Patients in their final days need immediate care to assure a comfortable and pain-free death; crisis management is often needed. Identifying priorities is an essential element. This includes involving the interdisciplinary team, clarifying goals of care, and providing excellent pain and symptom management. The following case study will help illustrate these points.
Mr. G was a relatively healthy 68-year-old man until 5 months before his hospice admission. At that time he was diagnosed with advanced gall bladder cancer and liver metastasis. Although he was in acute liver failure, with a recent hospitalization for a deep vein thrombosis and pulmonary embolus, he was still hoping for more chemotherapy, although he was too ill to tolerate it. During the hospice admission visit, he and his wife stated they desired full cardiopulmonary resuscitation if needed and they clearly communicated their desire for Mr. G to die at home. He died 6 days after admission to hospice. The first question to ask is simply, "Would your hospice admit this patient?" The patient is conflicted about hospice services and is not "hospice-minded." In other words, he has not taken the "hospice pledge": "Yes, I admit I am dying, and I fully agree with the hospice goals of care." It is a huge challenge for hospices to admit dying patients who are still in an approach-avoidance conflict with their terminality. This raises the issue of who can best provide patients with physical, psychosocial, and spiritual support needed to die comfortably with dignity.
Mr. G is an excellent example of the need for "crisis management" at the time of hospice admission. There are several "red flags" to be identified during the initial visit. Red flags include a relatively new diagnosis, the desire for more chemotherapy, conflicted emotions regarding hospice services, conflicted goals regarding CPR and place of death, significant clinical symptoms, and emotional and spiritual distress related to his rapidly advancing illness.
Based on best practices, the initial care plan includes the ability to quickly establish a therapeutic relationship, the art of compassionate conversations, and listening more than speaking. When possible, it is helpful to have a joint admission visit by the nurse and the social worker. Establishing an emergency plan is essential. The clinician should talk directly about what action to take if Mr. G's heart stops and/or he stops breathing before the next hospice clinical visit. The hospice clinician should ensure liquid morphine and lorazepam are in the home for management of dyspnea and/or pain and make certain that the care is coordinated with all healthcare providers so patients can have a smooth transition. The care plan should also include communicating to the after-hour staff the high-acuity needs of this patient and increasing visit frequency to daily, if needed, and finally, contacting the oncology practice to provide increased continuity of care to the patient.
Hospices must evolve to be better equipped at managing the acutely ill, dying, short-stay patients. Home hospice teams and palliative care teams are helping bridge the gap from aggressive, disease-modifying therapies to supportive hospice care. The keys to success are the skills of the hospice clinicians and the organization's capacity to deliver needed care. The true test of quality is the hospice's ability to care for these patients in a timely manner.
The prevalence of palliative care teams in hospitals have increased significantly. Recent data show that 66% of U.S. hospitals with more than 50 beds have a palliative team-an increase of 148.5% from 2000-2010 (Center to Advance Palliative Care, 2012). This growing practice trend will help patients and families understand the services of hospices and begin "the conversation" at an earlier date.
Until it is used for every patient, hospice crisis management for patients like Mr. G is necessary to ensure that appropriate quality care is delivered to ensure a comfortable death.
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