Laura S. Meiki, LMSW, Doctoral Student LNHA Social Services
Designee / Director Workshop June 21, 2012 Slide 2 It's strange
that they fear death. Life hurts a lot more than death. At the
point of death, the pain is over. - Jim Morrison Slide 3 OBJECTIVES
Provide an overview of hospice and palliative care in the nursing
home setting Discuss the role of social services with hospice
patients Clarify LaPOST and advance directives Highlight current
trends and issues in hospice/ palliative care Slide 4 Introduction
/ terminology HOSPICE Designed to give supportive care to people in
the final phase of a terminal illness. Focuses on comfort and
quality of life, rather than cure. The goal is to enable patients
to be comfortable and free of pain, so that they live each day as
fully as possible. Aggressive methods of pain control may be used.
Provides holistic care - support for the patient's emotional,
social, and spiritual needs in addition to medical symptoms as part
of treating the whole person. Family and loved ones are included in
care. Slide 5 PALLIATIVE CARE To palliate means to make comfortable
by treating a persons symptoms from an illness. The World Health
Organization (WHO) defines palliative care as an approach that
improves the quality of life of patients and their families facing
the problem associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification
and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual (World Health Organization
[WHO], 2007 ). Source: http://caringinfo.org Slide 6 PALLIATIVE
CARE/HOSPICE Palliative care is not the same as hospice. Hospice
provides palliative care, but one need not be in hospice to receive
palliative care. Palliative care can be provided at any stage of a
disease process. A patient may receive palliative care at the same
time as curative treatment. Slide 7 HOSPICE ELIGIBILITY Diagnosis
by two physicians (usually the patients PCP and the hospice medical
director) of a terminal illness with a life expectancy of six
months or less Philosophical shift from curative to palliative care
Patient and/or family agrees to hospice care SOURCE: www.sw.org
Slide 8 DIAGNOSES FREQUENTLY REFERRED TO HOSPICE Cancer Heart
disease Pulmonary disease Dementia Liver disease Renal disease
HIV/AIDS Parkinsons disease SOURCE: University of California
Academic Geriatric Resource Center
http://www.ucop.edu/agrp/docs/la_hospice.pdf Slide 9 WHEN IS A
PATIENT WITH DEMENTIA HOSPICE APPROPRIATE? * To be enrolled in
hospice, ALL of these signs and symptoms must be present: Unable to
walk without direct assistance Unable to dress themselves Need help
for bathing and grooming Unable to control bowel and bladder Might
use some language, but are unable to converse effectively *NOTE:
This diagnosis can only be provided by a physician SOURCE:
http://www.dementiacoalition.org/ Slide 10 WHEN IS A PATIENT WITH
DEMENTIA HOSPICE APPROPRIATE? * They must also have experienced at
least ONE of the following in the last year: Serious lung or kidney
infection Sepsis (sometimes called blood poisoning) Severe open
bedsores or pressure ulcers Persistent fever, even after
antibiotics Consistent inability to take food/fluids, or, lab test
results that indicate profound nutritional impairment *NOTE: This
diagnosis can only be provided by a physician SOURCE:
http://www.dementiacoalition.org/ Slide 11 THE MEDICARE HOSPICE
BENEFIT Covered under Medicare Part A Patient must sign a statement
choosing hospice care instead of routine Medicare covered benefits
for their terminal illness * The hospice must be a
Medicare-certified hospice *Medicare will still pay for covered
benefits for any health problems that are not related to the
terminal illness SOURCES: medicare.gov, ucop.edu Slide 12 THE
MEDICARE HOSPICE BENEFIT Currently, the benefits run for two
periods of 90 days followed by an unlimited number of 60 day
periods. At the end of each period, the patient must have benefits
renewed. To be renewed, a patient must still have the terminal
illness and must manifest a functional decline. SOURCE:
medicare.gov Slide 13 THE MEDICARE HOSPICE BENEFIT WHAT IS COVERED?
Physician visits Nurse visits Medical equipment Medical supplies
Drugs for symptom control or pain relief (patient may need to pay a
small copayment) Hospice aide and homemaker services Physical and
occupational therapy Speech-language pathology services SOURCE:
medicare.gov Slide 14 THE MEDICARE HOSPICE BENEFIT WHAT IS COVERED?
Social worker services Dietary counseling Grief counseling for the
patient and family Short-term inpatient care (for pain and symptom
management) Short-term respite care (may need to pay a small
copayment) Any other Medicare-covered services needed to manage
pain and other symptoms related to the patients terminal illness,
as recommended by the hospice team SOURCE: medicare.gov Slide 15
THE MEDICARE HOSPICE BENEFIT WHAT IS NOT COVERED? Treatment
intended to cure the patients terminal illness Prescription drugs
intended to cure the terminal illness (rather than for symptom
control or pain relief) Care from any hospice provider that wasnt
set up by the hospice medical team Room and board Care in an
emergency room, inpatient facility care, or ambulance
transportation, unless its either arranged by the hospice team or
is unrelated to the patients terminal illness SOURCE: medicare.gov
Slide 16 HOSPICE CARE SHOULD BE AVAILABLE TO ANYONE WHO NEEDS IT!!!
Hospice care is available to anyone who meets the admission
qualifications regardless of the patients ability to pay. Most
hospices* accept: Medicare Part A Private insurance Medicaid
Patients without funding *non-profit hospices Slide 17 THE HOSPICE
TEAM Medical director Attending physician Social worker Registered
nurses Home health aides Chaplain Volunteers Other modalities as
needed (PT, OT, etc.) Slide 18 THE HOSPICE TEAM SOCIAL WORK ROLE
Assess patient/family emotional, social, spiritual and financial
needs and develop plan of care to meet identified needs Provide
direct counseling and bereavement support to patients and their
families The philosophies of social work and palliative care
complement one another each taking into account the dying
individual in the full context of their life (Bosma et al., 2010)
quality of life should include quality of death (Roff, 2001). Slide
19 THE HOSPICE TEAM SOCIAL WORK ROLE Using the biopsychosocial
perspective to assess patients, social workers view patients
holistically, providing patients and families assistance with
emotional reactions, therefore aiding them in later making
difficult medical decisions (Snow et al., 2008). Slide 20
FACILITATING MEANINGFUL AND ENJOYABLE VISITS WITH HOSPICE PATIENTS
Activities visitors may enjoy doing with their loved one: Massaging
hands or feet with lotion Brushing his or her hair Singing familiar
songs Looking at a colorful book or pictures Saying favorite
prayers or poems Introducing favorite smells: cinnamon, fresh
grass, cologne, perfume, fresh baked cookies, and flowers Holding a
cuddly pet like a cat or dog Holding hands and just being together
Going outside to enjoy the air, the sunshine and the rest of nature
SOURCE: Simon Kassabian, MD, FACP Director, Palliative Care and
Deirdre Downes, LCSW Director Social Work, Jewish Home Lifecare
Slide 21 AS DEATH APPROACHES THE PROCESS OF ACTIVELY DYING Loss of
appetite and ability to swallow Decreased urine output Less
responsive and sleeps most of the time. Increasing weakness Loss of
ability to close eyes Pain may be evident Breathing changes can
fluctuate between slow and labored, quick and shallow Skin becomes
cooler and blotchy in the feet and hands SOURCE: Simon Kassabian,
MD, FACP Director, Palliative Care and Deirdre Downes, LCSW
Director Social Work, Jewish Home Lifecare Slide 22 AT THIS SPECIAL
TIME Provide the patient and family privacy, if possible. Place
chairs near the bed for visitors. Put pictures, flowers, or
religious objects on the bedside table. Place a sign on the door to
indicate the significance of this time and to make known the need
for privacy and quiet. Face the bed toward the window if it is not
too bright. Reduce bright lights. If the weather is nice, open a
window if possible. Spray the pillow or room with the persons
favorite scent. SOURCE: Simon Kassabian, MD, FACP Director,
Palliative Care and Deirdre Downes, LCSW Director Social Work,
Jewish Home Lifecare Slide 23 AT THIS SPECIAL TIME Remind visitors
that the sense of hearing is often the last sense to go encourage
visitors to communicate with the patient and NOT to talk about them
as if they were not present Dont forget that staff members are
family too and allow them special time to say goodbye Make sure
staff know hospice protocols for when death occurs they may be
different from facility protocols Slide 24 Thinking and talking
about death need not be morbid; they may be quite the opposite.
Ignorance and fear of death overshadow life, while knowing and
accepting death erases this shadow. -Lily Pincus Slide 25 LAPOST
The mission of the Louisiana Physician Order for Scope of Treatment
-- LaPOST -- is to improve end-of-life care in Louisiana by
honoring the health care wishes and goals of care of those with
life-limiting illnesses. Our goal is to empower consumers and
health care professionals with easy-to-access, simple-to-understand
information and resources to make educated decisions about
end-of-life care. SOURCE: http://lhcqf.org/ Slide 26 LAPOST The
LaPOST document and model of care were created to effectively
communicate the wishes of seriously ill patients to have or to
limit medical treatment as they move from one care setting to
another (e.g., hospital to home/nursing home/assisted living/home
health/hospice and vice versa). SOURCE: http://lhcqf.org/ Slide 27
LAPOST QUICK FACTS Standardized document available to all
physicians and patients in Louisiana Recommended for patients with
a life-limiting illness and irreversible condition Voluntary and
neither for nor against specific treatment Created to transfer with
patients through health care settings SOURCE: http://lhcqf.org/
Slide 28 LAPOST QUICK FACTS Requires the input of either the
patient or the patients personal health care representative Must be
completed and signed by a physician Becomes a binding medical order
once completed Can be changed or revoked at any time by the patient
or based on new knowledge by the patients personal health care
representative SOURCE: http://lhcqf.org/ Slide 29 END-OF-LIFE
DOCUMENTS End-of-life care preparation usually involves one or a
combination of three documents: LaPOST Advance directive (also
referred to as a living will) Health care power of attorney While
similar, each document requires specific planning. SOURCE:
http://lhcqf.org/ Slide 30 END OF LIFE DOCUMENTS LaPOST becomes
effective if a patient is unable to communicate. It is standardized
and available to all physicians and patients in Louisiana,
increasing the likelihood that a patients treatment preferences
will be fulfilled. SOURCE: http://lhcqf.org/ Slide 31 END OF LIFE
DOCUMENTS An advance directive, also referred to as a living will,
is a legal document stipulating treatment if an individual becomes
terminally ill and incapable of making decisions. This document
must be notarized. SOURCE: http://lhcqf.org/ Slide 32 END OF LIFE
DOCUMENTS A health care power of attorney is a document that allows
an individual to designate a proxy to oversee end-of-life treatment
once a patient is incapable of making decisions. NOTE: If multiple
end-of-life documents are completed, treatment preferences outlined
in the most recent document are followed. SOURCE: http://lhcqf.org/
Slide 33 CURRENT TRENDS & ISSUES In 2009, 83% of hospice
patients were adults over age 65. (National Hospice and Palliative
Care Organization 2010). Approximately 84% of hospice care in the
United States is funded by the Medicare Hospice Benefit, making it
the primary insurer for hospice services (Remington & Wakim,
2010). In 2009, the median length of service for hospice patients
was three weeks (NHPCO, 2010). Slide 34 CURRENT TRENDS & ISSUES
Today, there are about 5,000 hospices operating in the United
States (NHPCO, 2010). There are 126 hospices in Louisiana
(http://www.statehealthfacts.org/) Nonprofit versus for profit
hospices Slide 35 RESOURCES Social Work Hospice and Palliative Care
Network http://www.swhpn.org/ - membership includes subscription to
Journal of Social Work in End-of-Life and Palliative Care,
newsletters, policy updates National Council of Hospice and
Palliative Professionals (NCHPP)
http://www.nhpco.org/i4a/pages/index.cfm?pageid=3628 professional
membership associated with NHPCO - National Hospice and Palliative
Care Organization Slide 36 RESOURCES Louisiana-Mississippi Hospice
and Palliative Care Organization http://www.lmhpco.org/ Hospice
Eligibility http://www.ucop.edu/agrp/docs/la_hospice.pdf Medicare
Hospice Benefit
http://www.medicare.gov/publications/pubs/pdf/02154.pdf LaPOST -
http://www.la-post.org/
