Inpatient End of Life Care (Selby, 10/9/24)

A recording of this presentation on Inpatient End of Life Care is available HERE.

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We are so lucky in the hospital to have a talented and knowledgeable hospice liaison, Kristi Selby RN, who very much guides us through the process of transitioning patients onto hospice in the hospital. Most of those patients then discharge to home or the community, but occasionally we get to be witness to death of patient in the hospital. I am personally grateful for Kristi's attentive care of a patient with shared this past week.

I am also grateful to her for an excellent presentation she gave this week outlining the basics of hospice definitions, eligibility, services, and philosophy. Please watch the above link for the whole presentation. If you just want my notes, here they are:

Hospice is a level of care, not a place. Hospice offers expert medical care, pain management, emotional and spiritual support that is tailored to each patient (not to the disease). It includes facility support, bereavement for up to 18 months, and a focus on caring, not curing. It takes into account important aspects like anticipatory grief.

Just like many people these days have birth plans, hospice can help people have the death they want -- a death plan, of sorts. 

In order to be eligible for hospice, you need to have:

• terminal illness
• <6 months prognosis
• no curative treatment desired

While sometimes the condition of a "terminal illness" is obvious, but there are possible factors that can support eligibility for diagnoses that are less routine. These include: weight loss, a decrease in fluid/food intake, recurrent infections, increasing difficulty in attending to ADLs, frequent hospitalizations and/or ED visits, frequent falls with increasing weakness, and rapid progression of disease.

Some quantitative measures (e.g. Albumin <2.5 or EF <20%) can also help make patients eligible for hospice care. 

Additional information that may indicate hospice eligibility includes a change in function, a change in nutritional status, a change in weight, and a change in alertness. Don't forget to document these in your outpatient charts. AND, when in doubt, ask a hospice liaison for help!

Common barriers to entry into hospice include: 

• cultural/death taboo
• many people are unaware of hospice and hospice services
• family or providers don't want to take away hope
• there is a misunderstanding of what hospice is (it's not just give me morphine and kill me)
• death is really hard to talk about!

Hospice levels of care:

• Routine (multidisciplinary team with many visits/week in the home, SNF, etc)
• Continuous care (8 hours shifts, generally by RN)
• Respite care (short term, up to 5 days at a SNF for caregivers)
• General inpatient (GIP), in which a patient who is not stable to receive routine hospice care at home and/or needs up titration of medications can receive that level of care in the hospital

Routine hospice care gets reimbursed about $300/day; in contrast GIP costs Medicare about $2000/day so it must be justified on a daily basis. Issues that can justify GIP hospitalization include pain control, SOB, agitation, nausea/vomiting, wound care or any "skilled' needs

When a GIP patient is in the hospital, we focus on symptom management, which can be a shift for many hospital staff. Hospital care looks different for patients who are dying compared to those who are not dying. This can lead to nurse discomfort. It's important to talk about. In addition, more meds than we are generally accustomed to is better for comfort. We use benzos and opiates together in hospice care for comfort (the exact opposite of what we do for non-hospice patients). 

Finally, Kristi spent some time talking about how every person's situation is unique, every culture is distinct, and in hospice care we are really looking to provide the type of death the patient and their family desire. This may look very different than the type of death WE desire. That difference is okay, but we need to acknowledge it and be sure not to let our medical assumptions get in the way of what patients want.