Learning Objectives To understand hospice To understand the
philosophy of hospice To understand the barriers to hospice
admission To understand that conversations about death are crucial
To understand how advanced directives can start the conversation
about death To start the conversation in ones own life
Slide 4
The Hospice Philosophy The purpose of hospice is to provide
support and care for people in the final phase of a terminal
disease so that they can live as fully and comfortably as possibly.
Hospice affirms life and regards dying as a normal process. Hospice
neither hasten not postpones death. Hospice believes that through
personalized services and a caring community, patient and families
can attain the necessary preparation for death that is satisfactory
to them (National Hospice Organization, NHO, 2010).
Slide 5
What is Hospice? Takes care of those with a prognosis of six
months or less to live Focuses on caring, not curing Works to
control pain and other symptoms Recognizes dying as part of the
normal process of living Affirms life and neither hastens nor
postpones death Offers grief support after the death. Hospice
Foundation of America (n.d.)
Slide 6
Who & Where Hospice Eligibility Requirements A Medicare
patient must be certified by a physician as being terminally ill
with prognosis of 6 months or less Where do people use hospice?
Anywhere the client calls home, including moving to a facility if
needed (National Hospice Organization, 2014)
Slide 7
The inspiration for the modern hospice came from Dame Cicely
Saunders. Dr Saunders was an amazing woman of vision and
compassion. She received her medical degree in 1957 in the United
Kingdom. At that time she became the first modern doctor to
specialize in helping dying patients improve their quality of life.
Crucial to understanding the emotional dying process is Dr.
Elisabeth Kubler-Ross,and her bestselling book, On Death and Dying
in 1969. Her book was written after interviewing 500 dying
patients. Kubler-Ross pleas for home care and introduces the five
stages of grief. Beginning in 1982, Medicare began to offer hospice
as a benefit. This changed theory into reality. National Hospice
and Palliative Care Organization, NHPCO (2010 ) History of Hospice
Care
Slide 8
1. Death must be accepted 2. The patients total care must be
managed by a skilled interdisciplinary team whose members
communicate regularly. 3. The common symptoms of terminal disease,
especially the treatment of pain in all its aspects, needs to be
effectively controlled. 4. The patient and family must be
recognized as a single unit of care. 5. An active homecare program
should be implemented. 6. An active bereavement program must be
provided for family after the death of the patient. 7. Research and
education should be ongoing. (Sheehan,D., Forman, W., Kitzes, J.
2003, p.5) DR. SAUNDERS DEVELOPED THE FOLLOWING PRINCIPLES:
Slide 9
What is the Difference Between Hospice and Palliative Care?
Covered by Medicare Palliative Care Focus of care is quality of
life not curative Pain and symptom management for those with a
chronic, debilitating illness. DRG reimbursement Hospice Care Focus
of care is quality of life not curative Strictly for end-of-life
care Ideally, a patient would use palliative care first and then
flow naturally into hospice care if needed. (National Hospice
Organization, 2014)
Slide 10
Does Hospice Save Money? Hospice cancer patients used less
medical resources for non-hospice health needs. (Breitkopf,
Stephens, Jatoi,, 2013) Cancer patients who were discharged from
hospice used more health care resources. (Breitkopf, Stephens,
Jatoi,, 2013) Hospice patients were 16% less likely to die in a
hospital and used the emergency depart 11% less than their
counterparts. (Alonso-Babarro, et al., 2012) Medicare saved $1.26
for every $1.00 spent on hospice care (Hospice Association of
America, 2010)
Slide 11
Ineffective Use of Hospice 25% of hospice patients are enrolled
for less than one week. This, when maximum benefit is shown to be
80-90 days. 25% of deaths occur at home - more than 70% of
Americans would prefer to die at home. (Hospice Association of
America, 2010)
Slide 12
Root Cause Analysis Barriers to effective hospice usage Hospice
underused Patients are uncomfortable talking about death Doctors
are uncomfortable talking about death Hospice = Death Referrals
made too late Lack of advanced directive Lack of hospice
education
Slide 13
Culture of Death Denial Society (Whittington, 2011) Entire
culture hides and is protected of from death Hospice = death
Physicians (Tucker, 2009 ) Physicians lack education about death
Physicians view death as a failure This causes a delay in hospice
referrals Nurses (Chiplaskey, 2009) Nurses not educated to offer
quality end-of-life care. Nurses report they are afraid of speeding
up death.
Slide 14
When Should We Talk About Hospice? When is the right time? Now
Now Now - Now Talk about it before its needed
Slide 15
Why Should I talk about it? If we do not talk about death or
hospice we risk losing the opportunity to help someone finish their
final tasks of life Wont it diminish their hope for recovery?
Gaining meaningful life closure is worth it (Waldrop, Meeker,
2014). Completion of worldly affairs Sense of completion in
relationships Sense of meaning about ones individual life
Experience love of self Experience love of others Acceptance of
finality of life Sense of new self beyond personal loss Sense of
meaning about life Surrender to the transcendent, to the
unknown
Slide 16
How to Talk About Hospice Help for Physicians - S.P.I.K.E.S. S
etting, listening Skills Environment and knowledge of prognosis P
atients Perception Ask them what they know and what is most
important I nvite patient to share Information Is it OK if I talk
about hospice? Knowledge transmission What does hospice do E xplore
Emotions and Empathize Validate their feelings Summarize &
Strategize Can you tell me what you understand. I think hospice
would be a helpful thing for you (Talebreza, 2014)
Slide 17
Advanced Directives Can Advanced Directives start the
conversation? Advanced directives are the perfect place to start
not only the conversation with your patient but to change our
entire culture of Death Avoidance. In a survey of 7,900 people,
only 26% had an advance directive (NHPCO, 2013) Are advanced
directives associated with better hospice care? Patients with
advanced directives spent more time in hospice than average They
were more likely to die in their preferred setting. (Ache, Harold,
2014)
Slide 18
Theory Watsons nursing theory of human caring (Chantal, n.d.)
Communication and a trusting nurse-patient relationship Patient
gains a greater degree of harmony within the mind, body, and soul
Creates a healing environment (physical as well as non-physical)
Debbie Messer Zlatins Life Themes Psychology theory Focus on how
the dying person interprets his/her own reality as opposed to the
observer. She studied Life Themes: by interviewing dying people. A
dying person who had integrated life themes, were able to keep a
sense of who they are and what life meant. Caregiver s who are
informed of the dying person's life themes are more helpful to the
dying person (Jennings, n.d.)
Slide 19
ANA Standards Standard 5. Implementation A registered nurse in
a nursing role specialty fosters organizational systems that
support implementation of the plan. Standard 11. Collaboration
Partners with others to effect change and generate positive
outcomes though knowledge of the patient or situation. Standard 12.
Ethics Delivers care in a manner that preserves and protects
patient autonomy, dignity, and rights. (American Nursing
Association, 2004)
Slide 20
Quality and Safety Education for Nurses (QSEN) The goal of QSEN
is to prepare and educate nurses. They provide resources to develop
the knowledge, attitude, skills, and overall competence of nurses.
six focus areas Patient centered care Teamwork and collaboration
Evidenced base practice Quality improvement Safety Informatics
Slide 21
QSEN - Safety Mindfulness as both a means of self-care for the
caregiver and a doorway to empathy In patient care (QSEN, 2014) The
hospice nurse has all the same stressor including a lack of time
that create in inability to job to their satisfaction. Being
mindful to use coping strategies like a team approach can make
empathy available for patients. Shoshannah, S. (2012)
Slide 22
Recommendations Start the conversation about death and advanced
directives in your personal life How can we talk to our patients if
we cant talk to our family RNs should obtain education about end of
life care and communication skills Dispel myths about hospice
starve or hasten death To provide help to the community, we must
continue to educate on the culture of dying. What is a good
death?
Slide 23
Start the Conversation
Slide 24
References Ache, K., Harrold, J., Harris, P., dougherty, M.,
casarett, D., (2014) Are advanced directives associated with better
hospice care? Journal of Geriatric Society, 62(6): 1091-1096. DOI:
10.111/jgs.12851 Alonso-Babarro, A., Astray-Mochales, J.,
Domnguez-Berjn, F., Gnova-Maleras, R., Bruera, E., Daz-Mayordomo,
A., Cortes, C. (2012). The association between in- patient death,
utilization of hospital resources and availability of palliative
home care for cancer patients. Palliative Medicine, 27/68 DOI:
10.1177/0269216312442973. Retrieved from:
http://pmj.sagepub.com/content/27/1/68 American Nurses Association.
(2010). Scope and standards of nursing practice, second ed.
Washington, DC: American Nurses Publishing Breitkopf, C., Stephens,
E., Jatoi, A. (2013). Hospice in end-of-life patients with cancer:
does it lead to changes in nonhospice health care utilization after
stopping cancer treatment. American Journal of Hospice and
Palliative Medicine. Doi: 10.1177/1049909113488927. Retrieved from
http:/ajh.sagepub.com/content/31/4/392 Chantal, C., (n.d.) A
pragmatic view of JeanWatsons caring theory. International
Association of Human Caring. Retrieved from:
http://www.humancaring.org/conted/Pragmatic%20View.pdf
Slide 25
References Chiplaskey, L. (2009). End-of-life care: Are nurses
educationally prepared? Journal of Nursing. Retrieved from:
http://rnjournal.com/journal-of-nursing/end-of-life-
care-are-nurses-educationally-prepared Hospice Association of
America, (2010) Hospice facts and statistics. Retrieved from:
http://www.nahc.org/assets/1/7/HospiceStats10.pdf Hospice
Foundation of America, (nd).What is hospice? Retrieved from:
http://hospicefoundation.org/End-of-Life-Support-and-Resources/Coping-with-
Terminal-Illness/Hospice-Services Jennings, B., Gemmill, C.,
Bohman, B., Lamb, K. (n.d.). Kubler-Ross and other approaches.
University of Kentuky. Retrieved from:
http://www.uky.edu/~cperring/kr.htm National Hospice and Palliative
Care Organization, NHPCO (2010). Preamble and philosophy. Retrieved
from: http://www.nhpco.org/ethical-and-position-
statements/preamble-and-philosophy National Hospice and Palliative
Care Organization, NHPCO, (2010). History of hospice care.
Retrieved from: http://www.nhpco.org/history-hospice-care National
Hospice Organization, (2014). Hospice Eligibility Requirements.
Retrieved from:
http://www.nhpco.org/hospice-eligibility-requirements
Slide 26
References National Hospice Organization, NHPCO (2013). New
study on advance directives. Retrieved from:
http://www.nhpco.org/press-room/press-releases/new-study-
advance-directives Quality and Safety Education for Nurses. (2014).
Pre-licensure KSAS. Nursing Outlook Special Issue: Quality and
Safety Education. Retrieved from
http://qsen.org/faculty-resources/modules/learning-modules/module-three/
Sheehan, D., Forman, W., Kitzes, J. (2003). Hospice and Palliative
Care: Concepts and Practice. Sudbury, Ma: Publisher: Jones
&Bartlet Shoshannah, S., Walton, J., (2012). Caring for self:
The challenges of hospice nursing. Journal of Hospice &
Palliative Nursing. DOI: 10.1097/NJH.0b013e31825c1485. Retrieved
from:
http://journals.lww.com/jhpn/Abstract/2012/10000/Caring_for_Self__The_Challen
ges_of_Hospice_Nursing.11.aspx Talebreza, S.,Wildera, E., (2014).
The hospice referral. American Family Physician. Retrieved from:
http://www.aafp.org/journals/afp.html?cmpid=_van_188 Tucker, T.
(2009). Culture of death denial: Relevant or rhetoric in medical
education? Journal of Palliative Medicine. DOI:
10.1089/jpm.2009.0234 Whittington, F. (2011). Denying and defying
death: The culture of dying in 21 st century America. The
Gerontologist, Vol. 51, No. 4, 571579