HOSPICE CARE

NURSING
HCN 00
MONDAYS 10-11 SEC A
11-12 SEC B
2ND SEMESTER 2023
An Introduction to Hospice and Palliative
Care
• Hospice – healthcare dedicate to alleviating suffering in terminally ill
patients. Has been in the US for several decades. Large part is palliation of
distressing symptoms.
• Palliative care- considered a specialty distinct from hospice care.
• Goal : symptom management and support throughout the disease process.
• Patient and family/caregivers – are the unit of care, their needs are
addressed by members of the hospice interdisciplinary team.
• Interdisciplinary team approach- to deliver medical, nursing, social,
psychological, emotional and spiritual services through a collaboration of
professionals and caregivers.
• Goal : making the beneficiary as physically and emotionally comfortable as
possible.
• Hospice is compassionate beneficiary and family/caregiver centered care for
those who are terminally ill (Centers for Medicare and Medicaid Services,
2018 p. 38624
• Resources for hospice and palliative nurses include: *
• American Nurses Association ANA
• End-of-life Nursing Education Consortium ELNEC
• Hospice & Palliative Credentialing Center HPCC
• Hospice & Palliative Nurses Association HPNA
• National Hospice and Palliative Care Organization NHPCO
• The City of Hope.
CHARACTERISTICS OF HOSPICE CARE
• It is associated with terminality, fear on the part of patients and
families when the term is used
• Related with misperception, nearing death, all hope is lost, patient
will give up the will to live.
• The patient may fear his/her actual death, and the family may fear the
loss of their loved one (El-Jawahri et al, 2017)
• Hospice care focuses on physical, emotional and spiritual comfort of
terminally ill patients through interventions developed by IDT
• Hospice nurses may have expertise in symptom management and be
well versed in HOW each disease trajectory typically evolves.
• Care is specifically tailored to issues related to the terminal illness
• The patient agrees to forgo curative treatments
• Services are covered by the Medicare Hospice Benefit (if eligible)
• all end-of-life concerns are addressed in a holistic manner
• Patients receive skilled palliative care interventions to ensure comfort
• Care is mainly provided in the home (which may include facilities, if
this is where the patient resides; Coyle, 2015)
• Hospice care is generally provided for patients who have a life
expectancy of 6 months or less without life-sustaining treatment.
• Beyond 6-month, a patient may continue to receive services provided
that recertification requirements are met.
• HC continues through the disease process, during the dying process
and even after the patient’s death in the form of bereavement
support for the patient’s family and caregivers.
• *Palliative care nursing should be integrated into the nursing care of
older adults, with chronic illness to improve quality of care and to
promote physical, spiritual and emotional comfort. (Ferrell, 2019)
• National Institute on Aging 2017 defines palliative care as “ a resource
for anyone living with a serious illness (HF, COPD, CA, dementia, PD)
• PC can be helpful at any stage of illness and is best provided from the
point of diagnosis.
• It can be provided along with curative treatment and does not
depend on prognosis.
• PC includes symptoms management such as pain, dyspnea, NV,
fatigue and others that interfere with the patient’s ability to be
comfortable.
• PC can take place in various settings in clinic, hospital, long-term care
facility.
• It can be distinguished from other medical specialties by its foci on:
• Incorporation of interdisciplinary team to address spiritual, psychosocial and
cultural needs of patients and families
• Integration with curative treatments
• Symptom management in early stages of disease and throughout the disease
process
• Patient and family involvement in the plan of care (WHO 2019)
• *PC is not specified as Medicare benefit, Medicare Part B may cover some
treatments and services that are considered palliative.
• PC nurses have expertise in managing symptoms that disrupt patients’ and
their families quality of life.
• Pharmacologic and non-P measures are used to alleviate suffering, whether
plan of care is curative or promotion of comfort.
• Some hospitals have embraced the need for palliative services and have
gained certification through The Joint Commission. www. capc.org.
• Nurses as the 1st HCP to identify EOL concerns among patients, PC skills are
essential for developing a trusting therapeutic relationship with patient and
conveying needs to IDT (Dahlin & Wittenberg, 2019)
Differences Between Hospice and Palliative
Care
• HC- for terminally ill and dying patients
• PC- aimed promoting comfort for seriously ill whether terminal or not
• HC- bereavement services are provided up to 1 year after death
• PC – bereavement services are not always provided
• HC- care is primarily delivered at patient’s home
• PC- care maybe in acute care, long-term care, homes or other settings
• HC- patient chooses to forgo curative treatment
• PC- provided either curative or end-of-life treatments
• HC- covered by Hospice Medicare Benefit
• PC- may or may not be covered by Medicare or other health insurance plan
• HC- life expectancy is 6 months or less
• PC- life expectancy is not a factor.
HISTORY AND EVOLUTION OF
HOSPICE IN USA
• It is rooted in the end-of-life movement that came to US from Europe
in the later half of 20th century.
• Dame Cicely Saunders- an English nurse, social worker and physician
who is credited with founding the hospice movement. Her vision
involved:
• Developing a humane and systematic approach to end-of-life care,
• Devising an interdisciplinary approach to patient care
• Supporting the spiritual growth of patients and hospice staff,
• Easing the pain and suffering involved in dying
• Saunders anticipated that hospice workers would be organized in a
way similar to religious orders. For expansive hospice movement,
Saunders and her colleagues developed document “Aim and Basis”,
outlined the 5 premises of HC.
• 1st hospice, St. Christopher’s in London, 1967
• *Saunders’ passion for e-o-l care was fueled by her deep religious
convictions and her belief that ministering to the dying is a religious
calling (Wright & Clark, 2012)
• Dr. Elisabeth Kubler-Ross – a key researcher who advanced end of life
conversations by:
• Conducting interviews with dying patients in the mid 1960s
• Identifying that certain themes emerged over and over
• Publishing her groundbreaking work On Death & Dying in 1969, with 5
stages: denial and isolation, anger, bargaining, depression,
acceptance.
• Awareness of Dying book, Glaser and Strauss, 1965 offered how
physicians and nurses had little skill in the care of dying patients. They
found that HCP:
• Were quiet uncomfortable working with dying patients
• Tended to avoid dying patients because they felt ill-prepared to discuss death
• Increased their own feelings of ineptitude and distress by avoiding and
isolating dying patients.
• *Considered to be the model for quality, compassionate care for
people facing a serious or life-limiting illness or injury, hospice care
involves a team-oriented approach to expert medical care, pain
management, and emotional and spiritual support expressly tailored
to the patient’s needs and wishes (National Hospice and Palliative
Care Organization NHPCO, 2019).
• Medical training was mainly focused on fighting disease and
prolonging life.
• However, the growing interest in death and dying was already
creating perspective and driving changes in health care.
• 1974: the Connecticut Hospice, Inc. the 1st hospice to open in the US
began to provide end of life care (Simms, 2007)
• 1978: the National Cancer Institute provided funding to the
Connecticut Hospice, Inc. Purposes: developing a national
demonstration center for home care of terminally ill and their families
• By the end of 1978, there were 59 hospices in the US. (Greer, Morris
and Birnbaum, 1983)
• 1979: the Health Care Financing Administration funded an inquiry into
the scope of hospice services and the costs associated with this type
of care.
• 1982: Congress approved a provision that covered hospice services
under Medicare Part B. the provision included a sunset clause, which
meant it would end in 1986 without congressional action.
• Fast Facts: the Hospice Medicare Benefit covers services from doctors,
nurses, nurse practitioners, nurses’ aides, therapists, social workers,
chaplain and volunteers.
• Medical equipment, supplies and medications that are related to the
terminal illness are also covered.
• Respite care is available in an inpatient facility for up to 5 days each
month (Centers for Medicare and Medicaid Services, 2018)
• 1983: US Senate report from the Committee of Finance chaired by
Sen Robert Dole, collected data about hospice and reported hospice
care was more effective and cost efficient than end-of-life care
provided in the hospital setting. The average savings were $2,485 per
patient. Today’s terms would be $5,000 per patient.
• 1984: The Joint Commission began accrediting hospice organizations
• 1986: Recognizing the benefits of care of the dying patients, Congress
voted to make the Hospice Medicare benefit permanent.
• 1991: Hospice care was recommended for inclusion in veterans
benefits NHPCO
• 1993: Hospice care became a nationally guaranteed benefit, and President
Clinton recognized November as National Hospice Month.
• 1994: The 1st certification examination for hospice nurses was administered
through the Hospice and Palliative Credentialing Center (HPCC, 2019)
• 1997: The Balanced Budget Act included several provisions for hospice care,
such as an updated payment structure, revised benefit periods and
expanded coverage.
• 2000: the end-of Life Nursing Education Consortium Nursing ELNEC
developed to provide training for RN. Today, over 24,000 nurses and other
HCP have attended ELNEC courses (American Association of Colleges of
Nursing, 2019).
• 2001: The National Consensus Project, an interprofessional meeting
to discuss end-of-life care in the US, took place in NYC.
• 2004: National Quality Forum NQF released “A national framework
and preferred practices for palliative and hospice care quality: A
consensus report”
• 2009: Updated clinical guidelines were created and released through
a collaboration among the 1. American Academy of Hospice &
Palliative Medicine, 2. The Center for the Advancement of Palliative
Care, 3. The Hospice & Palliative Care Organization 4. National
Hospice & Palliative Care Organization.
• 2010: The Patient Protection & Affordable Care Act included
provisions for the delivery of high-quality palliative and e-o-l care.
• 2011: The Joint Commission launched Advanced Palliative Care
Certification opportunities for qualifying healthcare organizations;
• 2015: The Centers for Medicare and Medicaid Services introduced 2
new billing codes for advance care planning provided for Medicare
beneficiaries;
• 2016: The Centers for Medicare & Medicaid Services introduced a
two-tiered payment system for routine home care, decreasing
payment for routine visits after the 60th day of hospice service.
• However, a service intensity add-on was introduced, increasing
payments to hospice organizations caring for patients during the last 7
days of life (National Association for Home Care & Hospice, 2017)
• 2018: Passage of the Medicare Patient Access to Hospice Act enabled
physician assistants to serve as attending physicians for hospice patients
(American Academy of Physician Assistants, 2018)
• Numerous national and international efforts to improve care for
terminally ill patients continue each year.
• Today, HC is available in every state in America, hospice and palliative
certification is available for both RN and advance practice nurses
(Hospice & Palliative Credentialing Center, 2019).
• For the past 50 years, e-o-l care has been rapidly expanding in the US
• Aided by pioneers in the field and numerous legislative changes.
• Hospice Medicare Benefit ensures access to HC for all Americans at the
EOL
• For nurses providing e-o-l care, certification is available and HC is now a
recognized specialty.
You can differentiate and elaborate between Hospice & Palliative Care
You can demonstrate & identify an understanding of HC, its turning
points, how research helped shape EOL, and the legislative changes that
supported HC in the US.