Hospice and Palliative Care:

An OverviewPatrick J. Macmillan, MD, FACPDivision of Palliative Medicine

Department of Internal MedicineEast Tennessee State University

James H. Quillen College of Medicine

Introduction

What is Palliative and Hospice Medicine?

Disease that are most frequently seen

Hospice guidelines

Evidence for Palliative and Hospice Care

Resources

Philosophy

Emphasize advanced planning and ongoing care and support rather than crisis intervention

Promotion of psychosocial and spiritual growth and development

No specific therapy is excluded—treatment is based, however, on meeting treatment goals rather than effect on underlying disease

Radiation, chemotherapy, surgery are NOT excluded in palliative or hospice care

History: Western Civilization

Earliest recorded hospice 475 in Rome

Middle Ages: Christian religious orders in Europe

Modern hospice movement: Irish sisters of charity 1879

St. Christopher’s Hospice 1967 in London remains one of the preeminent hospice programs in the world

First hospice program in US opened in 1974 in New Haven, CT

1996 450,000 patients were served by 2,700 hospice programs

Alternatives

Quality of Life

Medical Ethics

Palliative Care

Medical Care for people with serious illnesses—focuses on relief from symptoms and suffering

Palliative medicine is the study and management of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is quality of life.

WHO: “active total care of patients whose disease are NOT responsive to curative treatments.”

Is Palliative Care the same as Hospice?

Palliative Care

NO—Hospice is a “focus” of Palliative Care targeted at the terminally ill

Goals: Improve quality of life for family and patient

Give patient a voice in Tx Plan

Appropriate at any stage of serious illness

Palliative Care

“Patient and Family centered care that optimizes quality of life by anticipating, preventing and treating suffering.

A continuum of treatment that focuses on all aspects of a person

NQF National Framework and Preferred Practices for Palliative and Hospice Care

Palliative Care

Referral: complications, uncontrolled symptoms, multiple comorbidities, and patient or family distress

Assistance needed for complicated decision-making

Palliative Medicine

Lancet September 2010; Double-blind, randomized controlled trial

Study comparing Palliative O2 vs. Intranasal room air

239 patients, life-limiting illness, refractory dyspnea and PaO2>55

Each group received either O2 or room air at 2L/min NC

Conclusion: No significant difference in rating of dyspnea; air movement across the face (hand held fan) helps relieve dyspnea

Oxygen is costly and risky for some patients

Simple interventions can be used in case where there is NOT true hypoxia

Hospice Care

Hospice Care: 6 months or less to live IF disease runs its natural course. (Also need family consent)

Hospice Care

Cancer, COPD, Heart disease, ESRD, ESLD, Dementia, CVA, AFTT, Debility, AIDS

NHO (National Hospice Organization) medical guidelines

Cancer: Cancer plus metastasis (clinical findings) with widespread aggressive and progressive disease

PPS score of < 70%

Patient refusing further Tx

Hospice Care

COPD: Severe and progressive lung disease

FEV1<30% predicted

ER visits or hospitalization for lung infections

Hypoxemia at rest (o2 sat<88%)

Hypercapnea (Pco2 >50 mm Hg)

Best indicator is FEV1

Hospice Care

Heart Failure

New York Heart Association Class IV (Sxs at rest)

Optimal Tx

Other: refractory arrhythmias, hx of cardiac arrest, syncope

Can be on transplant list

Hospice Care

Dementia

Severe Dementia and 1st occurrence of medical complications

Severity: unable to ambulate independently, no meaningful conversation, urinary/fecal incontinence, unable to dress/bathe independently. “total care”

Medical complications: UTI’s, aspiration PNA, wt loss, etc.

Documentation of rapid decline

Hospice Care

HIV Disease

CD4 count<25

Viral Load >100K copies/mL

Decreased functional status

Other: CNS Lymphoma, PML, wasting, MAC bacteremia, refractory Toxoplasmosis

Note: 80% HIV patients alive 10 years after seroconversion

Hospice Care

End-stage liver disease

INR>1.5 and Albumin <2.5 gm/dl

Clinical syndromes: Ascites in spite of diuretics, SBP, Hepatorenal syndrome, Hepatoencephalopathy despite lactulose

Recurrent variceal bleed

Other: active etoh abuse, Hep B, CA, malnutrition

Note: Patients can be on hospice pending liver transplants

Hospice Care

End-stage renal disease

No dialysis

Lab criteria: creatinine >8.0 and clearance <10

Others: CVA, coma, ALS, MS, Parkinson’s disease, AFTT, debility

Hospice/Palliative Care

90% of Americans die after living with a chronic, progressive incurable illness

1/3 of healthcare costs occur in last year of life

Duke University Study (2007): hospice saves Medicare an average of more than $2,300 for each hospice beneficiary

Reduction in Medicare costs if hospice recipients been on for a longer period

Hospice patients lived an average of 29 days longer than those not referred to hospice

Hospice/Palliative Care

Study: 228 ambulatory patients with newly diagnosed non-small cell lung cancer

Standard oncologic care vs. palliative care

Palliative care group survived longer (11.6 months vs. 8.9 months)

Analysis (included age and performance status) showed early palliative care was an independent predictor of survival

Subgroup (107 patients in both groups) survived to 12 weeks—PC group reported better quality of life

Hospice/Palliative Care

Palliative care group received less chemo

Made fewer ER visits

More likely to die at home

Resource Use in the Last 6 Months of Life Among Medicare Beneficiaries With Heart

Failure, 2000-2007

Archives of Internal Medicine: Retrospective cohort study: February 14, 2011

US patients, 200,000 Medicare beneficiaries who died in 2000-2007

Use of hospice increased from 19% to 40% over the course of the study

Average number of days in ICU increased

80% of patients were hospitalized in last 6 months of life

Hospice/Palliative Care

Assessed length of patients stay in hospice

19% stayed < 3 days, 37% < 1 week

Hospice Use and High-Intensity Care in Men Dying of Prostate Cancer

Archives of Internal Medicine: Retrospective cohort study 2011

Hospice use among men dying of Prostate CA between 1992-2005

53% used hospice—22% of this group enrolled in hospice < 1 week

Conclusion: “short stays [in hospice] don’t allow patients to receive full benefits of enrollment in hospice.”

Hospice/Palliative Care

Study did find an increase in use of hospice care over time

Hospice patients less likely to receive high-intensity care

Conclusion: “Increasing the appropriate use of hospice care for patients at end of life could both improve quality of death and reduce ineffective health care expenditures.”

Hospice/Palliative Care

Late referrals are due partly to physicians attitudes about death

May view patients death as a medical or personal failure

May feel they have nothing else to offer when curative goals are exhausted

Distance themselves from patients and families because uncomfortable talking about death

Hospice/Palliative Care

Prognosis-related issues also problematic

Accurately predicting prognosis is difficult (particularly non-cancer diagnosis)

Best Prognosticators: length of practice, subspecialists

If you have known the patient a long time---less accurate

Hospice/Palliative Care

The Good News

Changes in attitudes regarding advanced diseases and improving quality of life

More acceptance of Palliative care concept

Access to palliative care improving

Curriculum changes in medical school