reference guide - aarp® medicare plans about hospice in the continuum of hospice care, hospice...

R e f e r e n c e G u i d e

Covers_07 9/7/07 3:33 AM

Contents

About Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medical Indicators for Hospice . . . . . . . . . . . . . . . 4

Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Congestive Heart Failure (CHF) . . . . . . . . . . . . . . 6

Chronic Obstructive Pulmonary Disease (COPD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Alzheimer’s Dementia . . . . . . . . . . . . . . . . . . . . . . . . . 8

Neurological (CVA, Coma, Parkinson’s, etc.) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Liver Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Debility Unspecified . . . . . . . . . . . . . . . . . . . . . . . . . 11

ALS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Renal Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

AIDS/HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Primary Care Guide — Opioids

IV and Oral Opioid Therapy . . . . . . . . . . . . . . . . 17

Transdermal Fentanyl . . . . . . . . . . . . . . . . . . . . . . . . 18

Methadone Conversion Table . . . . . . . . . . . . . . 18

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Primary Care Guide — Non-opioids

Neuropathic Pain Analgesics . . . . . . . . . . . . . . . 19

Non-steroidal Anti-inflammatory Drugs(NSAIDS) and Non-opioids . . . . . . . . . . . . . . . . . 20

NSAID Side Effects and Precautions . . . . . . 22

Primary Care Guide — Non-pain Symptoms

Adjuvant Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Pharmacological Symptom Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Primary Care Guide — Useful Resources

Breaking Bad News (SPIKES) . . . . . . . . . . . . . . . 27

Hospice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Spirituality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Wong-Baker FACES Pain Rating Scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Karnofsky Performance Status . . . . . . . . . . . . . . . . 31

Palliative Performance Scale version 2 . . . . . . . 32

In-patient or Continuous Care . . . . . . . . . . . . . . . . 34

About Our Company . . . . . . . . . . . . . . . . . . . . . . . . . . 36

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1

About HospiceIn the continuum of hospice care, hospiceprofessionals strive for “a good death,”where patients receive personal, emotionaland spiritual comfort; are freed from painand suffering, and are surrounded byloved ones. Hospice brings a team ofspecially trained professionals who offertools, experience and interventions tofacilitate a peaceful death that occurs withrespect and dignity.

Evercare Hospice and Palliative Careprovides end-of-life care coordination andservices through a holistic team approach,working collaboratively to fulfill thephysical, psychological and spiritual needsof patients and their families during auniquely personal time of transition.

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2

Hospice has been demonstrated toimprove the quality of life for patients with life-limiting conditions and disease,including:

• Cancer

• Cardiovascular Disease

• Congestive Heart Disease

• Chronic Obstructive PulmonaryDisease (COPD)

• Dementia or Alzheimer’s Disease

• Neurological Disease (Parkinson’s, ALS, etc.)

• Renal Disease

• Liver Disease

• Acquired Immune DeficiencySyndrome (AIDS/HIV)

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3

Under Medicare, and most otherinsurance, people are eligible for theHospice benefit if two physicians certifythat they have a life expectancy of sixmonths or less if the disease runs itsnormal course. Some indications thatpeople may meet this criteria include:

• Progressive decline in functional statusdespite curative treatments

• Frequent hospitalizations or ER visits

• Repeat or multiple infections

• Increased or uncontrolled pain

• Progressive/profound weakness and fatigue

• Shortness of breath with or without oxygen

• Dependency (decrease in ADLs)

• Alterations in mental status

• Weight loss

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Med

ical

Ind

icat

ors

fo

r H

osp

iceMedical Indicators

for Hospice

IndicatorsTabs_07 9/7/07 10:36 AM Page 1

4

* Copyright Victoria Hospice Society, BC, Canada (2001)www.victoriahospice.org

Medical Indicators for HospiceThe evidence-based best practices on the following pages are accepted medicalindicators for hospice eligibility.

The PPS values given are taken from theVictoria Hospice Palliative PerformanceScale,* which can be found atwww.victoriahospice.org/pdfs/PPSv2.pdf

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Can

cer

Cancer


5

Cancer

• Treatments not curing disease

• Failed multiple treatments

• Increasing pain and/or symptoms

• Multiple trips to hospital for symptom management

• Metastasis and/or Stage 3 or 4

• Toxicity outweighs benefits

• Poor performance status:- ECOG of 3 – 4- Karnofsky or PPS value <50

• Terminal prognosis with only a few treatments left

• Exhausted patient andfamily/caregivers

• Treatment is having negative impact on patient’s quality of life

• Patient/family wants to stop curative treatment

The guidelines given for each disease are predictive forpatients with a single condition. Additional comorbiditiesor complications should be taken into consideration whenevaluating appropriateness for hospice care.

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Co

nges

tive

Hea

rt F

ailu

re

(CH

F)

Congestive Heart Failure

(CHF)


6

Congestive Heart Failure (CHF)

• Class IV functional status (NYHA)

• Ejection fraction <20%

• Optimal diuretic and vasodilatortherapy

• Recurrent symptoms of CHF at rest

• Persistent symptomaticsupraventricular or ventriculararrhythmia

• History of cardiac arrest or resuscitation

• History of unexplained syncope

• Brain embolism of cardiac origin


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Chr

oni

c O

bst

ruct

ive

Pul

mo

nary

Dis

ease

(CO

PD

)

Chronic Obstructive

Pulmonary Disease (COPD)


7

Chronic Obstructive PulmonaryDisease (COPD)

• Disabling dyspnea at rest

• Oxygen dependent

• O2 saturation less than 88% on room air

• Recurrent infections

• Poor response to bronchodilators

• FEV1 after bronchodilator less than30% of predicted

• Heart failure secondary to pulmonary disease

• Resting tachycardia greater than 100 beats per minute

• Weight loss greater than 10% overprevious six months

• Increasing visits to the emergencydepartment or hospitalization, orincreased MD/NP visits to maintainpatient in current living situation


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Alz

heim

er’s

Dem

enti

a

Alzheimer’s Dementia


8

Alzheimer’s Dementia

Stage 7 or higher on FAST:

• Unable to ambulate alone

• Unable to dress, bathe or feed self

• Incontinent of bowel and bladder

• Unable to speak or communicatemeaningfully

Presence or history of at least one co-morbid condition in the past year, such as:

• Weight loss

• UTI

• Aspiration

• Pneumonia

• Decubitus ulcers

• Septicemia


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Neu

rolo

gic

al (C

VA

, Co

ma,

Par

kins

on’

s, e

tc.)

Neurological

(CVA, Coma,

Parkinson’s, etc.)


9

Neurological (CVA, Coma, Parkinson’s, etc.)

• Karnofsky or PPS value less than 40%- Unable to ambulate alone- Unable to dress, bathe or feed self- Incontinent of bowel and bladder- Speech limited

• Poor nutritional status, dysphagia,and/or more than 10% weight loss

• Serum albumin less than 2.5 grams per dl

• Dysphagia (history of aspiration)


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Live

r D

isea

se

Liver Disease


10

Liver Disease

• Documentation of specific liver disease

• Jaundice

• Ascites

• Abnormal liver enzymes

• Elevated PT greater than 5 seconds; INR >1.5

• Encephalopathy

• Spontaneous bacterial peritonitis

• Recurrent variceal bleeding

• Positive HBSAG (Hepatitis B)

• Hepatitis C refractory to interferon


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Deb

ility

Uns

pec

ified

Debility Unspecified


11

Debility Unspecified

While many providers use “adult failure to thrive” to describe irreversible declinein the elderly, fiscal intermediaries forMedicare more often utilize the term“debility unspecified.”

Debility unspecified syndrome ischaracterized by unexplained weight loss, malnutrition and disability. Thesyndrome has been associated withmultiple primary conditions, but alwaysincludes two defining clinical elements,namely nutritional impairment anddisability. The nutritional impairment and disability associated with the debility unspecified syndrome may besevere enough to affect the patient’s short-term survival.

Debility unspecified syndrome maymanifest as an irreversible progression in the patient’s nutritionalimpairment/disability despite a trial of therapy. The presence of co-morbidconditions may hasten the patient’s clinical progression and as such should be identified and addressed.


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The medical criteria below supports the terminal prognosis for patients withdebility unspecified syndrome:

• Nutritional impairment is severeenough to impact patient’s weight;Body Mass Index (BMI) is below 22 kg/m2

• Patient declines enteral/parenteralnutritional support, or

• Does not respond to nutritionalsupport, despite adequate caloric intake

• Karnofsky or PPS value less than or equal to 40%


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ALS

ALS


13

ALS

1. The patient must demonstrate critically impaired breathing capacity as demonstrated by all the followingcharacteristics occurring within the 12 months preceding initial hospicecertification:

• Vital capacity (VC) less than 30% of normal

• Significant dyspnea at rest

• Requires supplemental oxygen at rest

• Patient declines artificial ventilation

2. Patient must demonstrate both rapid progression of ALS and criticalnutritional impairment as demonstratedby all the following characteristicsoccurring within the 12 monthspreceding initial hospice certification:

• Progression from independentambulation to wheelchair or bedbound status

• Progression from normal to barelyintelligible or unintelligible speech

• Progression from normal to pureed diet


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• Progression from independence in most all ADLs to needing majorassistance by caretaker in all ADLs

• Oral intake of nutrients and fluidsinsufficient to sustain life

• Continuing weight loss

• Dehydration or hypovolemia

• Absence of artificial feeding methods

3. Patient must demonstrate life-threatening complications as demonstrated by one of thefollowing occurring within the 12 months preceding initial hospice certification:

• Recurrent aspiration pneumonia (with or without tube feeding)

• Upper urinary tract infection; e.g., pyelonephritis

• Sepsis

• Recurrent fever after antibiotictherapy


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Ren

al D

isea

se

Renal Disease


15

Renal Disease

Any one of the following criteria meetsMedicare guidelines:

• Creatinine greater than 8 mg per dl; or greater than 6 mg/dl in diabetics

• Urine output <400 ml/24 hours

• Patient/family choose to discontinuechronic dialysis

• Hepatorenal syndrome

• Hyperkalemia not responsive to treatment

• Intractable fluid overload


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AID

S/H

IV

AIDS/HIV


16

AIDS/HIV

CD4 lymphocyte count less than 25 with a viral load greater than 100,000 copies,plus one of the following:

• Central nervous system lymphoma

• Persistent wasting

• Mycobacterium avium complexuntreated or unresponsive to treatment

• Progressive multifocalleukoencephalopathy

• Systemic lymphoma

• Visceral Kaposi’s sarcoma unresponsiveto treatment

• Renal failure

• Cryptosporidium infection

• Toxoplasmosis

• Karnofsky performance or PPS valueless than 50


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Pri

mar

y C

are

Gui

de

Op

ioid

s

Primary Care Guide

Opioids


17

IV and Oral Opioid Therapy

Drug EquianalgesicDose (mg)

Usual StartingDose

Oral IV/SC Oral IV

Meperidine(Demerol®) Notrecommended by APS

300 75

Codeine 300

Morphine, short acting

30 10 5-15 mgq3 hours

2-4 mgq2 hours

Morphine, long acting (MS Contin®,Oramorph SR®)

30 15 mgq12hours

Hydrocodone(Vicodin® – withTylenol®)

30 5-15 mgq3 hours

Oxycodone, short acting(Roxicodone®,Percocet® – withTylenol)

20 5-10 mgq3 hours

Oxycodone, long acting(OxyContin®)

20 10 mgq12hours

Hydromorphone(Dilaudid®)

7.5 1.5 2-4 mgq3 hours

0.5-1 mg q2 hours

Fentanyl 0.08

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Daily MorphineDose(mg/24 hr PO)

Conversion Ratios

Morphine PO Methadone PO

<100 3 1

101 - 300 5 1

301 - 600 10 1

601 - 800 12 1

801 - 1000 15 1

>1000 20 1

A typical q8-q12h dose is 2.5 - 5 mg q8h.If converting from high doses of other opioids, themaximum dose after conversion should never exceed 30 mg q8h.

Methadone Conversion Table

Transdermal Fentanyl

Morphine 37.5 mg orally = Fentanyl 25 mcg/hin 24 hours transdermal patch

Patch dose as mcg/h ~ Fentanyl IV rate in mcg/h

Requires adipose tissue — Not indicated in adults under 120 pounds

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No

n-o

pio

idsPrimary Care Guide

Non-opioids


19

Neuropathic Pain Analgesics

Drug Usual Dose Range Comments

Anti-convulsants

Carbamazepine(Tegretol®)

Start at 200 mg PO qHS; � dose up to 600-800 mgPO daily (dividedBID to TID)

Check serumdrug levels andWBC

Gabapentin(Neurontin®)

Start 100 mg PO TIDx 1 day, 200 mg TIDx 2 days; then �dose; max >4000mg/d & up

Reduce with renalimpairment

Pregabalin(Lyrica®)

Start 50 mg TIDMax 600 mg/day

Reduce with renalimpairment

Tricyclic Anti-depressants (TCAs)

Desipramine(Norpramin®)

10-25 mg PO qHSMax 300 mg/day

Preferred TCAin elderlypatients

Nortriptyline(Pamelor®)

Start at 25 mg PO qHS; � dose to75-150 mg qHS

Preferred TCAin elderlypatients

Serotonin/Norepinephrine Reuptake Inhibitor (SNRI)

Duloxetine(Cymbalta®)

60 mg/day Reduce with renal and no usewith liverimpairment

Other Options

Clonazepam (Klonopin®) Phenytoin (Dilantin®)Lidocaine 5% (Lidoderm®) Tiagabine (Gabitril®)Lamotrigine (Lamictal®) Topiramate (Topamax®)Methadone Valproic Acid (Depakote®)

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Non-steroidal Anti-inflammatory Drugs(NSAIDS) and Non-opioids

NSAIDstrengths available

Dose (starting) Max DailyDose

Acetic Acids

Diclofenac Sodium(Voltaren®) 25, 50, 75 mg (IR) 100 mg (ER)

50 mg TID (IR)100 mg daily(ER)

225 mg

Indomethacin* (Indocin®) 25 & 50 mg (IR) 50 mg supp (ER)75 mg & 25 mg/5 ml (ER)

25-50 mg BID – TID (IR)75 mg daily (ER)

200 mg

Diclofenac Potassium* (Cataflam®), Sulindac* (Clinoril®), Tolmetin (Tolectin®)

COX-2 Inhibitors

Celecoxib (Celebrex®)100 & 200 mg

100 mg BID or 200 mg qd

400 mg

Naphthylakones

Nabumetone (Relafen®)500 & 750 mg

1000 mg daily ormay divide BID

2000 mg

Fenamates

Meclofenamate Sodium*(Meclofenamate®)50 & 100 mg

50 mg q4-6 hours

400 mg

Mefenamic acid* (Ponstel®)

Oxicams

Piroxicam (Feldene®)10 & 20 mg

10 mg daily 20 mg

Proprionic Acids

Ibuprofen*(Motrin®, Advil®)200, 400, 600, 800 mg &100 mg/5 ml

400 mg every 4-6 hours

3200 mg

Naproxen andNaproxen Sodium(Anaprox®, Naprosyn®,Aleve®) 220, 250, 375, 500mg & 125 mg/5 ml

220 mg-275 mgPO q6-12 hoursNaprelan®

750 mg daily

1500 mgNaproxenbase

Fenoprofen* (Nalfon®), Flurbiprofen (Ansaid®),Ketoprofen* (Orudis®), Oxaprozin (Daypro®)

NSAIDS continues on next page

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Non-steroidal Anti-inflammatory Drugs(NSAIDS) and Non-opioids continued

NSAIDstrengths available

Dose (starting) Max DailyDose

Pyranocarboxylic Acid

Etodolac(Lodine®, Lodine XL)200, 300 & 400 mg (IR)400, 500, 600 mg (ER)

200-400 mg q6-8 hours (IR)400 mg daily (ER)

1200 mg

Pyrrolizine Carboxylic Acid

Ketorolac (Toradol®)10 mg PO15 mg/ml, 30 mg/ml IV

30 mg q6 hoursIM/IV unless >65y/o, <50 kg, orrenal disease;then 15 mg q6 hrs

120 mg IVunless risks,then 60 mgMax 5 days

Salicylates – Acetylated

Aspirin* 81, 165, 325,500 & 650 mg

325-650 mg q4-6 hours

3200 mg

Diflunisal (Dolobid®)

Salicylates – Non-acetylated

Choline MagnesiumTrisalicylate (Trilisate®)500, 750 & 1000 mg &500 mg/5 ml

500-750 mg TID 3000 mg

Salsalate (Disalcid®)500 & 750 mg

500-750 mg TID 3000 mg

Other Agents

Acetaminophen*(Tylenol®)

325-650 mg q4-6 hours

4000 mg2000 mgwith liverimpairment

Tramadol (Ultram®) 300 50 mg q4-6hours

Steroidal

Dexamethasone(Decadron®) 0.25, 0.5,0.75, 1, 1.5, 2, 4, & 6 mg;0.5 mg/5 ml & 1 mg/ml

2-4 mg q12-24 hours


IR = Immediate release productsER = Extended release products*FDA approved indication for pain

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Non-steroidal Anti-inflammatory Drugs(NSAIDS) and Non-opioids continued

• All NSAIDs are equally effective

• Variable pharmacodynamics may be responsible for individual’s lack of response

• Give NSAID adequate trial of 2 – 3 weeks

• If NSAID does not work, then select from different class or samechemical class

NSAID Side Effects and Precautions

Side Effects:

• epigastric distress

• renal insufficiency

• hepatotoxicity

• hypersensitivity reactions

• platelet inhibition (cox-1 NSAIDS)


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NSAID Side Effects and Precautionscontinued

� Risk of GI Bleeding*

• elderly (age > 65 years)

• concomitant corticosteroid or anticoagulant use

• large NSAID doses

• long-term NSAID therapy

• history of peptic ulcer disease or GI event (e.g., bleeding)

� Risk of Renal Toxicity**

• elderly (age > 65 years)

• existing renal problems

• diuretic use

• concurrent treatment with nephrotoxic drugs

* Increased risk of GI bleeding with cox-1 NSAID activity. Cox-2 NSAIDS have less GI side effectscompared to cox-1.

** Increased risk of renal toxicity with both cox-1 and cox-2 NSAID activity.

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n-p

ain

Sym

pto

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Primary Care Guide

Non-pain Symptoms


24

Adjuvant Agents

Drug ClassTypical 1st Choice

Comments

AntidepressantDesipramine

Adjuvant analgesic, depression

Antiemetic(prokinetic)Metoclopramide

Vomiting 20 gastritis, gastricstasis, & functional bowelobstruction. Anorexia-cachexia,constipation

Antiemetic(area postrema)Haloperidol

Chemical causes of vomiting,e.g., opioids, hypercalcemia,renal failure. Agitation, delirium

Antiemetic(vomiting center)Cyclizine, Meclizine,Scopolamine

Mechanical bowel obstruction,increased intracranial pressure,motion sickness

AntitussiveHydrocodone

BenzodiazepinesLorazepam

Anti-convulsant, anxiety,delirium, insomnia

CorticosteroidsDexamethasone

Adjuvant analgesic, anorexia-cachexia, antiemetic,asthenia, delirium, dyspnea

LaxativeSenna, Lactulose

NeurolepticsHaloperidol

Agitation, delirium, antiemetic

StimulantMethylphenidate

Asthenia, depression, sedation

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Pharmacological SymptomManagement

Drug Usual Dose Onset to Peak

T 1⁄2

Anorexia

Dexamethasone 2-8 mgPO/IV qAM

1-2h 36-54h

Megestrol Acetate 400 mg PO BID

1-5h 1h

Dronabinol, eicosapentaenoic acid, melatonin,metoclopramide, mirtazepine

Anxiety/Agitation

Lorazepam 0.5-2 mgPO/SL q4hPRN

1-6h 10-20h

Alprazolam, chlorpromazine, escitalopram, haloperidol,midazolam, mirtazapine, paroxetine, quetiapine, sertraline

Asthenia (Weakness)

Dexamethasone 2-8 mgPO/IV qAM

1-2h 36-54h

Methylphenidate 5 mg POqAM &qnoon

1-3h 3-4h

Megestrol acetate

Oral Secretions (Death Rattle)

1% Atropine Eye Drops

1-3 gttsqhour

10 min 2-3h

Scopolamine 1.5 mg Patch

apply q3days 24hours

5h

Glycopyrrolate 0.2 mg(IV/SC) or 2 mg (PO)q6-8h

1-45min

1.7h

Hyoscyamine

Constipation

Sennosides (Senna®) 15-100 mgPO daily

6-12h ?

Bisacodyl, docusate sodium, lactulose, magnesium hydroxide, metoclopramide

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Pharmacological SymptomManagement continued

Drug Usual Dose Onset to Peak

T 1⁄2

Delirium – Terminal Restlessness

Haloperidol 0.5-2 mgPO/SC/IVBID and q4hPRN

10-20min

17h

Chlorpromazine, lorazepam, midazolam, olanzapine,quetiapine

Depression

Desipramine 25-300 mgdaily

2-6h 14-62h

Citalopram, duloxentine, escitalopram, methylphenidate,mirtazapine, nortriptyline, paroxetine, pemoline,sertraline, venlafaxine

Dyspnea

Morphine 5-30 mgPO/SL/PRq3h

1⁄2-1h 2-4h

Albuterol, aminophylline, dexamethasone, ipratropium,oxygen, theophylline

Insomnia

Temazepam 7.5-30 mgqHS

1-2h 8-10h

Chlorpromazine, eszopiclone, indiplon, ramelteon,trazodone, zaleplon, zolpidem

Nausea/Vomiting

Haloperidol(decrease motility)

0.5-2 mgPO/SC/IVq4h PRN

3-6h 17h

Metoclopramide(increase motility)

10-20 mgPO/SC/IVTID or QID

1⁄2-2h 4-6h

Meclizine(central, vestibular)

25 mg PO BID

1h 6h

Chlorpromazine, dexamethasone, diphenhydramine,dronabinol, lansoprazole, ondansetron, olanzapine,omeprazole, prochlorperazine, ranitidine, quetiapine

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Use

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eso

urce

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Primary Care Guide

Useful Resources


27

Useful Resources

Breaking Bad News (SPIKES)(Baile, Buckman et al, 2000)

SettingAppropriate and without interruption

PerceptionWhat do you know/understand of the condition?

InvitationIs everyone present, and how much information do you want?

KnowledgeDeliver the information as appropriate

EmpathizeAnd explore emotion

StrategySummarize and make a plan

Pronouncing a Death

• Recognize the extreme emotionalsignificance.

• Introduce yourself and establish eye contact.

• Identify the patient by ID bracelet.

• Assess response to verbal and gentletactile stimulus.

• Examine patient for absence of breathand heart sounds.

• Note time of death.

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• When confirmed, verballyacknowledge death to family.

• Communicate condolences verbally or non-verbally.

• Inform family about formalities as appropriate.

• Notify nursing staff and attending of time of death.

Anticipatory Grief

Five things patients and families need to say:

Forgive me

I forgive you

Thank you

I love you

Good-bye

Hospice

What It Is

• A program emphasizing quality of liferather than prolongation of life

• An insurance benefit that is providedby an interdisciplinary team available24 hours a day regardless of patient setting

• All services (interdisciplinary team,medications, supplies, bereavement)related to the terminal condition are covered

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Eligibility

• Two physicians certify prognosisaverages less than 6 months (Usually the primary and the Hospicemedical director)

• Patient and family goals aremaximizing quality over quantity

Typically Does Not

• Cover treatments that do not targetspecific symptoms

• Provide caregivers or custodial care

Spirituality“That which gives meaning to one’s life and draws one to transcend oneself”

– (Center to Improve Care for the Dying)

SPIRIT (Maugen, 1996)

Spiritual belief system — what is important and of value

Personal spirituality — where does the person get support

Integration with a spiritual community

Ritualized practices and traditions

Implications for medical care — what is the meaning of the illness

Terminal events planning — unfinished business

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30

Wong-Baker FACES Pain Rating Scale

10 Hurts worst

9

8 Hurts whole lot

7

6 Hurts evenmore

5

4 Hurts little more

3

2 Hurts little bit

1

0 No hurt

All rights reserved. The information contained here is general in nature and should be used in conjunction with nationally recognized guidelines. It should not beconstrued as medical advice or opinion. No liability will be assumed for its use, and accuracy is not guaranteed.“FACES Pain Rating Scale” from Wong DL, Hockenberry-Eaton M, Wilson D, Winkelstein ML, Schwartz P: Wong’sEssentials of Pediatric Nursing, ed. 7, St. Louis, 2005, p.1259. Copyrighted by Mosby Inc. Reprinted by permission.

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Kar

nofs

ky

Per

form

ance

Sta

tus

Karnofsky

Performance Status


31

Karnofsky Performance Status

GeneralCategory Index Specified Criteria

Able to carry onnormal activityand to work; no special careneeded

100 Normal, no complaints; no evidence of disease

90 Able to carry on normalactivity; minor signs orsymptoms of disease

80 Normal activity with effort;some signs or symptoms of disease

Unable to work;able to live athome and carefor most personalneeds; varyingamount ofassistanceneeded

70 Cares for self; unable tocarry on normal activity orto do active work

60 Requires occasionalassistance, but is able tocare for most of his or herpersonal needs

50 Requires considerableassistance and frequentmedical care

Unable to carefor self; requiresequivalent ofinstitutional orhospital care;disease may be progressingrapidly

40 Disabled; requires specialcare and assistance

30 Severely disabled; hospitaladmission is indicatedalthough death notimminent

20 Very sick; hospitaladmission necessary; active supportive treatmentnecessary

10 Moribund; fatal processesprogressing rapidly

0 Dead

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Pal

liati

ve

Per

form

ance

Sca

le

Palliative Performance

Scale version 2

(PPSv2)


32

Palliative Performance Scaleversion 2*

PP

S Le

vel

Am

bul

atio

nA

ctiv

ity

& E

vid

ence

o

f D

isea

seSe

lf-C

are

Inta

keC

ons

cio

us L

evel

100%

Full

Nor

mal

act

ivity

& w

ork

No

evid

ence

of d

isea

seFu

llN

orm

alFu

ll

90%

Full

Nor

mal

act

ivity

& w

ork

Som

e ev

iden

ce o

f dis

ease

Full

Nor

mal

Full

80%

Full

Nor

mal

act

ivity

with

effo

rtSo

me

evid

ence

of d

isea

seFu

llN

orm

al o

r re

duc

edFu

ll

70%

Red

uced

Una

ble

nor

mal

job

/wor

kSi

gni

fican

t d

isea

seFu

llN

orm

al o

r re

duc

edFu

ll

60%

Red

uced

Una

ble

hob

by/

hous

e w

ork

Sig

nific

ant

dis

ease

Occ

asio

nal

assi

stan

ce n

eces

sary

Nor

mal

or

red

uced

Full

or c

onfu

sion

* Reprinted with permission, Victoria Hospice Society

Palli

ativ

e Pe

rfor

man

ce S

cale

con

tinue

s on

nex

t p

age

InsidePages_07 9/7/07 4:13 AM Page 32

33

Palliative Performance Scaleversion 2* continued

* Reprinted with permission, Victoria Hospice Society

PP

S Le

vel

Am

bul

atio

nA

ctiv

ity

& E

vid

ence

o

f D

isea

seSe

lf-C

are

Inta

keC

ons

cio

us L

evel

50%

Mai

nly

sit/

lieU

nab

le t

o d

o an

y w

ork

Exte

nsiv

e d

isea

seC

onsi

der

able

assi

stan

ce re

qui

red

Nor

mal

or

red

uced

Full

or c

onfu

sion

40%

Mai

nly

in b

edU

nab

le t

o d

o m

ost

activ

ityEx

tens

ive

dis

ease

Mai

nly

assi

stan

ceN

orm

al o

r re

duc

edFu

ll or

dro

wsy

+

/- c

onfu

sion

30%

Tota

lly b

edb

ound

Una

ble

to

do

any

activ

ityEx

tens

ive

dis

ease

Tota

l car

eN

orm

al o

r re

duc

edFu

ll or

dro

wsy

+

/- c

onfu

sion

20%

Tota

lly b

edb

ound

Una

ble

to

do

any

activ

ityEx

tens

ive

dis

ease

Tota

l car

eM

inim

al t

o si

ps

Full

or d

row

sy

+/-

con

fusi

on

10%

Tota

lly b

edb

ound

Una

ble

to

do

any

activ

ityEx

tens

ive

dis

ease

Tota

l car

eM

outh

car

e on

lyD

row

sy o

r co

ma

+/-

con

fusi

on

0%D

eath

InsidePages_07 9/7/07 4:13 AM Page 33

In-p

atie

nt o

r C

ont

inuo

us C

are

In-patient or

Continuous Care


34

In-patient or Continuous CareGeneral in-patient or continuous care isdesigned for people that require acutemedical management in licensed facility or in-home RNs respectively. Licensedfacilities must have an RN on premises 24 hours a day, and continuous care is at least eight hours of nursing a day and at least half must be delivered by an RN.Indications include the following:

Intractable pain

• Unmanageable pain, whether or not it can be expressed verbally or throughnonverbal signs

• Ongoing pain control/managementrequiring frequent adjustment in dose;or analgesia requiring constantmonitoring and evaluation

• Non-verbal signs of pain (groans and grimaces)

Severe intractable symptoms

• Nausea, vomiting, diarrhea, etc.

• Respiratory distress, including hypoxia,airway compromise, and dyspnea

Complicated medical care

• Complicated wound care or dressing changes

• Complex medication administration

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Abrupt changes in psychosocial problemsand uncontrolled symptoms, which cancreate significant stress on thepatient/family:

• Abrupt change in behavioral orcognitive abnormalities causing severe agitation, disorientation, or combative behavior

• Severe depression and/or anxietynecessitating a change in environmentfor safety

• Suicide ideation, gestures, attempts,threats of euthanasia

• Acute breakdown or disruption infamily dynamics, preventing familymembers from functioning asadequate caregivers (either physicallyor emotionally)

• Death is imminent with unstablesymptoms and caregiver distress

Seizures requiring intensive intervention,continuous monitoring, and medications

Hemorrhage or bleeding causingsymptoms that are difficult for the familyto manage

Other symptoms defined by theinterdisciplinary team as unmanageable by the family

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36

About Our CompanyAt Evercare® we’re dedicated to providinghealth care coverage and other servicesfor the elderly and people with disabilitiesand chronic illnesses. We offer health planswith benefits and services specificallydesigned to help those who need it most.

Our plans make it easier for you to get the care you need. With an Evercare health plan you get access to an EvercareNurse Practitioner or Care Manager whohelps arrange for services and monitorsyour care.

Whether you live alone, with your family or in a facility, Evercare has a health planfor you. We have plans for people withMedicare and Medicaid. We also offerMedicare plans for people in nursingfacilities and special Medicare plans forpeople with chronic conditions such asdiabetes, heart disease and kidneydisease. And Evercare Hospice & PalliativeCare provides services for people withadvanced illnesses and those nearing the end of life.

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Evercare is more than health plans. We’re people who care, dedicated tohelping you get the health care youdeserve.

In the complex world of health care,Evercare makes getting care easier.

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reference guide - aarp® medicare plans about hospice in the continuum of hospice care, hospice...

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