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21/Jan/2021

When the time arises for a loved one to be enrolled in hospice care, determining a payment method is understandably the furthest thing from the minds of the family members.  Precious Healthcare can assist families in navigating the payment aspect of enrollment in hospice care.

Hospice services are covered by Medicare, Medicaid and most private health insurance providers, and Precious will never turn away a patient in need based on being uninsured or underinsured.

Medicare

The most common form of insurance for patients who receive hospice care is Medicare.  The Medicare Hospice Benefit is available to beneficiaries who are covered under Medicare Part A, and covers the cost of hospice care including medications and equipment related to the patient’s diagnosis.  Patients who utilize the Medicare Hospice Benefit are still eligible for coverage under Medicare Part B for any services that are not related to their terminal illness.

U.S. citizens and many legal residents qualify for Medicare at the age of 65.  Medicare also covers those under the age of 65 who have End-Stage Renal Disease (ESRD) or who have received Social Security Disability Income payments for 24 months (or for one month for patients with ALS).

Medicaid

Medicaid is a state-funded program that affords medical coverage for patients who have limited financial means.  If a patient’s income is slightly higher than the amount for Medicaid eligibility, “spend-down” amounts must be satisfied in order to access maximum coverage of this benefit. The Medicaid Hospice Benefit also covers the costs of hospice care including medications and equipment related to the patient’s diagnosis.  

Both Medicare and Medicaid Hospice Benefits reimburse Precious for hospice services.

Medicare HMO Coverage for Hospice

The Medicare HMO transfers coverage to Medicare Part A for hospice benefits and the entirety of the aforementioned Medicare Hospice Benefit applies.

Private Insurance

Hospice benefits can vary significantly among private health insurance plans, so Precious will verify and negotiate benefits for patients with commercial or private health insurance.

Coverage will be determined at the time of hospice admission, and the allowable benefits will be explained clearly.  In most cases, Precious negotiates a daily rate that provides coverage for hospice services.  As with any healthcare benefit plan, deductibles and co-payments may be applied to the hospice benefit.

Coverage for the Uninsured

If a patient does not have health insurance coverage, Precious will provide services based on need, regardless of his or her ability to pay.

Discontinuation of Hospice Services

Patients have a right to choose at any time to discontinue their hospice services. Occasionally, patients may choose to pursue active treatment or alternative medical benefits as opposed to continuing with hospice care.  With appropriate notification, this transition can be easily achieved.  Also, Medicare, Medicaid and most private health insurance providers allow for hospice benefits to be reactivated at a later date.

You have Options

Medicare, Medicaid, Medicare HMO and most private insurance companies allow you to choose your own provider for hospice services regardless if the hospice is outside of the HMO network.  Allow us to be there for you during life’s precious moments.


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21/Jan/2021

Being in an industry where compassion is woven into the framework presents its own set of challenges.  Health care providers who care for patients with serious illness need to have a well-developed sense of empathy, however continuously providing compassion for others without also providing adequate care for oneself can be harmful to even the best-intentioned healthcare provider.  Multiple negative emotions can commonly result when a patient is nearing the end-of-life, including grief, fear, conflict and desperation.  Healthcare professionals are not immune or exempt from these emotions that can easily be contagious during such difficult times.  

Signs of Compassion Fatigue

According to an article published in Family Practice Management, compassion fatigue is defined as “a deep physical, emotional and spiritual exhaustion accompanied by acute emotional pain,” (Pfifferling, et al., 2000). It can appear differently in each individual, but according to the authors, common symptoms of compassion fatigue include:

  • Anger
  • Depression or anxiety
  • Gastrointestinal problems
  • High blood pressure
  • Addictive behaviors
  • Difficulty sleeping
  • Physical or emotional exhaustion
  • Irritability
  • Diminished self-esteem

Self-Care and Coping Strategies

Ideally, healthcare professionals should possess what researchers call “compassion satisfaction” which is defined in an article published in the Journal of Psychiatric Nursing as “the pleasure you derive from being able to do your work well, creating new life values” while compassion fatigue is defined as “a negative consequence that occurs when helping with the pain and trauma of the individuals being cared for,” (Yilmaz, G. & Ustun, B, 2018).  Self-care can improve the element of compassion satisfaction.  Other than the typical stress-eliminating techniques (exercise, creating boundaries, etc.), some other methods have shown to help compassion fatigue specifically, such as self-awareness and rituals.

Self-Awareness

Research that was reported in the Journal of the American Medical Association has shown that engaging with patients and situations in a highly conscious, and aware state—specifically moment to moment—could assist in preventing compassion fatigue with healthcare providers.  The idea is to practice mindfulness by paying close attention to one’s own emotions and reactions (their internal reality), while consciously working to meet the needs of others (their external reality). The researchers identified that this mindful approach to working, combined with mindful meditation and journaling, has shown to reduce stress, enhance well-being and increase empathy in healthcare providers, (Kearney, M. K., et al., 2009).

Rituals

In an online survey of hospice staff across 38 states, 71% of respondents reported using personal rituals such as lighting candles, praying, attending funerals and calling patients’ family members. The results were published in the Journal of Palliative Medicine, and showed that professionals who developed rituals around the death of their patients, scored higher on a compassion-satisfaction scale and lower on a burnout scale, (Montross-Thomas, L. P., et al, 2016). 

Make sure to maintain the usual antidotes to compassion fatigue, such as eating well, resting well, and exercising.  Additionally, before taking on the role of the rock that everyone else leans on, implement some mindful activities to keep yourself on an even keel.

References

Pfifferling, J-H., & Gilley, K. (2000). Overcoming compassion fatigue. Family Practice Management, 7(4), 39-44. https://www.aafp.org/fpm/2000/0400/p39.html?printable=fpm

Kearney, M. K., Weininger, R. B., Vachon, M. L. S., Harrison, R. L., & Mount, B. M. (2009). Self-care of physicians caring for patients at the end of life. Journal of the American Medical Association, 301(11), 1155-1164. https://jamanetwork.com/journals/jama/article-abstract/183563

Montross-Thomas, L. P., Scheiber, C., Meier, E. A., & Irwin, S. A. (2016). Personally meaningful rituals: A way to increase compassion and decrease burnout among hospice staff and volunteers. Journal of Palliative Medicine, 19(10), 1043-50. https://www.liebertpub.com/doi/abs/10.1089/jpm.2015.0294

Yilmaz, G. & Ustun, B. (2018). Professional quality of life in nurses: Compassion satisfaction and compassion fatigue. Journal of Psychiatric Nursing 9(3), 205-11. https://jag.journalagent.com/phd/pdfs/PHD-86648-REVIEW-YILMAZ[A].pdf


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21/Jan/2021

For patients that are eligible for hospice, the Medicare Hospice benefit covers the identified four levels of care.  The payments from Medicare include all services, medications, equipment and supplies related to the terminal illness for each level of care. 

Precious is able to transition patients who are eligible to hospice care so they are able to take advantage of all of the covered services and supplies that are available to them.

The four levels of care are categorized as the following:

Routine Home Care

The majority of hospice services are provided via routine home care.  In 2015, 98.7% of hospice care provided was in this category.  Routine home care includes scheduled, routine visits in the home by a multidisciplinary care team, including hospice physician, registered nurse, hospice aide, social worker, chaplain, volunteer and bereavement specialist. “Home” is defined as the patient’s residence, which may be a private home, assisted living facility or nursing facility.

Continuous Home Care

Continuous home care is available during times of crisis when a higher level of continuous care is needed for at least eight hours in a 24-hour period to achieve palliation or management of acute medical symptoms.  Fifty percent of the care needed must be provided by a nurse.

Inpatient Care

Some patients have short-term symptoms so severe they cannot get adequate treatment at home, or they may feel more comfortable getting treatment at an inpatient facility.  Symptoms requiring inpatient care are the same as those requiring continuous care, only the setting of care may be different.  With inpatient care, nurses are available around the clock to administer medications, treatments, and emotional support to make the patient more comfortable.

Respite Care

Primary caregivers are at risk for burnout—respite care can provide a temporary break.  Respite care services are more for the family than for the patient.  If the patient does not meet the criteria to qualify them for continuous care or inpatient care, but the family is having a difficult time, respite care may be an option.  If a patient’s family is the primary source of care and cannot meet their loved one’s needs due to caregiver stress or other extenuating circumstances, a patient may temporarily be admitted to an inpatient environment to give the family a needed break.There is a five-day limit on respite care. Once that period expires, the patient is discharged and returns home.

References

Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2004). CMS manual system. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r15bp.pdf.


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21/Jan/2021

The coronavirus (Covid-19) pandemic has caused a difficult and unprecedented period for health care providers, patients and their families globally.   

Precious Healthcare understands the magnitude and impact of the current landscape and is dedicated to providing updated, clear information about Covid-19 and its impact, as well as how we will continue to respond to the virus as an organization.

These frequently asked questions provide information about safety protocols for staff, patients, and families in our facilities and under our care. 

As the situation changes and our handling of Covid-19 evolves, this FAQ will be updated to reflect the latest information available to us.

Is hospice care available during the coronavirus pandemic?

Precious Hospice accepts referrals, and continues to visit hospice patients.  Our staff has the appropriate training, and necessary personal protective equipment to ensure the safety of patients while providing services in their homes during this pandemic.

Does Precious accept patients who test positive for Covid-19?

Our team is trained and prepared to provide care should a hospice-eligible patient who tests positive for Covid-19 be referred.

Must hospice patients with suspected or confirmed infections of Covid-19 be hospitalized? 

As with any other infection, Covid-19 calls for an individualized approach to care.

Will the Precious team assist in relieving symptoms of Covid-19 for an infected patient?

The Precious team consists of experts in managing symptoms that patients commonly experience near the end of life.

Are elderly patients at a higher risk of contracting Covid-19? How can Precious help?

The Centers for Disease Control and Prevention (CDC) states that those at higher-risk for severe illness from Covid-19 are:

  • People 65 and older
  • People of any age who have a serious underlying medical condition
  • People who live in nursing homes and long-term care facilities

Precious has a successful history of caring for medically fragile older adults. Hospice nurses have extensive training to prevent infections, manage pain, improve quality of life, and reduce unwanted trips to the emergency room.

How will Precious staff members conduct safe patient visits during the Covid-19 pandemic?

The Precious team will continue to adhere to the established screening protocols to evaluate the risk of contraction and spread of infection through each patient encounter.

What steps is Precious taking to make sure at-home hospice patients are safe during the Covid-19 pandemic?

Your health and safety are our highest priorities. We are taking extra safety precautions during every face-to-face visit, as our team is adhering to safety guidelines from the Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and state/local health departments.

Specific Steps taken by our team include:

  • Daily fever and symptom-free certification by all visiting staff
  • Implement droplet precautions when caring for patients with respiratory infection
  • Use of personal protective gloves with all patients
  • Additional hand hygiene before and after visiting facility/home

What about telehealth options during the coronavirus pandemic?

Virtual hospice care visits enable us to safely connect patients and their families with our doctors, nurses, chaplains, and social workers. 

What factors should be considered when caring for a hospice patient in their home during the Covid-19 pandemic?

During a time of crisis like the Covid-19 pandemic, family members and close friends continue to provide daily care.  Caregivers should develop and sustain habits and strategies to maintain their own health and well-being. This will help to limit viral transmission, and to avoid the consistent risk of burnout in caregivers.  Also, hospice patients at home should be separate from other people and animals as much as possible (a separate room ideally).  The Precious team can help you with extra safety measures, such as when and how to wear a face covering. 

Does Precious test for Covid-19?

For patients, Precious follows the recommendations from the Centers for Disease Control and Prevention (CMS), and state/local health departments which are based upon several factors like test availability, facility concerns, and the impact of a test result altering the plan of care.

During the coronavirus outbreak, can Precious help with providing extra supply needs (i.e. masks, gloves, wipes) for patients and their families?

As always, the Precious team will do whatever we can to meet the needs of our patients and their families.

Can a Precious social worker or spiritual care coordinator visit a hospice patient during the Covid-19 pandemic?

All Precious team members, including physicians, nurses, aides, social workers, spiritual care coordinators, and bereavement specialists, are following all safety guidelines from the Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and state/local health departments. 

Can I still volunteer for Precious during the Covid-19 pandemic?

At Precious, we are always recruiting volunteers. However, during the Covid-19 pandemic we are only accepting volunteers on a virtual basis. Luckily, you can make a difference from the comfort of your home!

For more information about Covid-19 cases, guidelines, and recommendations, please visit the following websites:

https://www.cdc.gov/coronavirus/2019-ncov/index.html

https://www.cms.gov/medicare/quality-safety-oversight-general-information/coronavirus


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21/Jan/2021

Hospice is focused on doing the very best that you can with the circumstances present.  After it is established that no cure exists for the illness of a loved one, the idea of “hope” takes on a different meaning.  There is a shift in the paradigm of hope, as it then means to do everything possible in order to satisfy the loved one’s wishes and to reduce their pain and suffering.  The focus shifts to comfort care provided in the familiar environment of their home, with family and friends near.

Hospice is the Next Critical Step of Care in the Continuum 

When clinical providers have come to the point where nothing more can be done for a patient, because there is no imminent cure for a particular condition, hospice care offers the next critical step of care in the continuum.  Contributing to the quality of life for the patient and their family is of the utmost priority, and hospice allows for goals related to quality of life to be met.

Focus Shifted to Spending Quality Time

It is likely that before a terminal diagnosis is reached, the patient’s loved ones are consumed with various concerns such as physician appointments, evaluation of possible treatments and cures, attempting to manage pain and symptoms, and more.  Upon finalizing and accepting a diagnosis, utilizing hospice care can provide an extremely significant relief, where spending quality time can be the new focus for loved ones and the patient can receive the quality care they deserve.

Solicited Care

When patients with terminal illness elect to utilize hospice care, the additional care can allow for patients to potentially live a bit longer than those who do not receive hospice care.  With the comfort associated with living at home, surrounded by loved ones, hospice patients can also experience a strong sense of relief, and furthermore, more control and choice within their circumstances.  The differentiated, and specialized care that is provided by the hospice interdisciplinary team can not only reduce suffering, but also allow the patient and their loved ones to spend more quality time together, and ultimately give back to the patient a sense of dignity.

Enrolling in hospice care is not giving up!  Hospice care is another aspect of patient-centered care within the continuum that provides to patients and their families the support they need to live their final days at home with an improved quality of life, and surrounded by those they care most about.


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21/Jan/2021

In hospice care there is a need for difficult conversations that lead to even more difficult decisions by healthcare providers, their patients and families. Of the most challenging conversations is that about commencing, maintaining or removing artificial nutrition and hydration (ANH) as a patient nears the end-of-life.

These decisions are complex for various reasons, including medical and ethical guidelines, along with the consideration of the emotions of patients and their families.  In addition, difficult questions about withholding food and water at the end of life will arise, and the religious, cultural, spiritual and personal factors that are involved with a loved one’s forthcoming death further complicate the conversation.

Hospice care providers can maneuver these difficult decisions by fostering engaging conversations that are rooted in empathy and well-informed by their expert clinical knowledge, skills and experience. 

Create an Individualized Plan for Hospice Care 

Proactive care planning demonstrates an optimal method for the patient and family to clearly explain the wishes and values of the patient before the patient becomes unable to do so. Providers can inform patients and families of the process of natural death, inclusive of the role that ANH may play.  The interdisciplinary team can be an indispensable source that they can rely on to effectively conduct such conversations so that all standards, including medical, ethical and professional, are met, or exceeded.

Since each patient’s prognosis, needs, and objectives of care vary, the decisions regarding ANH should always be established after thoughtful, transparent and informative conversation that needs to address the following:

  • Specific diagnosis and prognosis (how ANH will impact each)
  • Medical issues (the implications for or against ANH)
  • Non-medical issues (the personal, cultural and religious beliefs and values of the patient and their family and how these can be respected in the hospice plan of care)
  • Quality of life (if ANH will increase or decrease suffering)
  • Goals of care (if the decisions related to care will reinforce the wishes and values of the patient)

Provide Education to Family Members About the Dying Process

Current research does not support the claim that withholding food and water at the end-of-life contributes to suffering and/or the prolongation of life.  This should be incorporated into the discussions with the patient and family as well as the creation of the specified plan for hospice care. Furthermore, as the condition of the patient changes, the plan for hospice care should change appropriately also.

It is important that the clinical staff in the interdisciplinary team mitigate the associated emotional issues by reassuring the family that the team is not “giving up on” or “starving” a patient in hospice care who stops eating or drinking.  On the contrary, the team should provide education to their patients and families regarding the human body’s natural dying process, including the fact that the digestive tract shuts down with an increasing incapacity to process food and liquids. Patients’ families can find reassurance in understanding that as food and liquid intake decelerates, the patient’s body often also releases the “feel-good” endorphins naturally to relieve pain.

The Benefits and Risks/Complications of Tube Placement: 

For hospice patients the following overall guidelines address feeding tubes:

  • Existing feeding tube: If patients are enrolled in hospice with already existing feeding tubes, physicians should work closely with patients, their families and any other caregivers to make decisions with regard to if and when to reduce or cease ANH. As a patient nears the end of life, ANH can be responsible for discomfort, aspiration and development of bedsores, absent of the advantage of prolonged life.
  • Placing a new feeding tube: Typically, feeding tubes are not placed for patients once they are admitted into hospice care. Rarely, a decision will be made, with collaboration between the patient, family and interdisciplinary team, to proceed with implementing a feeding tube.

Generally, research shows that ANH does not extend life or lengthen longevity of survival.  However, it has shown that it can be connected with various difficulties that decline the quality of life for the patient.  Typical difficulties caused by ANH include irritation, infection, blockage, discomfort, aspiration pneumonia, bleeding, reflux, uncontrolled diarrhea, limited socialization/movement, frequent replacement or removal of tubes, a lack of proper oral care, and elevated utilization of physical and/or chemical restraints. Tube feeding near the end-of-life can also develop sensations of “drowning” or uncomfortable “fullness” for the patient.

As an example of prognosis-based guidelines, the American Geriatric Society, American Academy of Hospice and Palliative Medicine, and The Society for Post-Acute and Long-Term Care Medicine do not recommend feeding tubes for patients with advanced Alzheimer’s/dementia, but instead, recommend oral assisted feeding, (Teno, J., et al, 2014).

Frequently Asked Questions from Healthcare Providers Regarding ANH at End-of-Life:

  1. Do feeding tubes prevent malnutrition?  Not necessarily, as many people that are on hydration and feeding tubes still experience malnutrition due to their underlying disease, immobility, and/or neurologic deficits (but not typically from a lack of food and water).
  1. Do feeding tubes prevent bedsores or expedite healing?  ANH can increase urine output, stools, diarrhea, upper airway secretions, and immobility, which can all intensify and increase bedsores, as well as interfere with the overall healing of existing wounds.
  1. Do feeding tubes reduce the mortality rate?  According to research, life expectancy is virtually identical for patients who are offered ANH at the end-of-life with those who are not offered it.
  1. Do feeding tubes prevent aspiration pneumonia? Current research does not support the claim that feeding tubes reduce the risk of aspiration pneumonia or regurgitated gastric material.  On the contrary, some evidence indicates that there is an increased risk of aspiration, as patients with tubes can still aspirate gastric material and oral secretions, or even suffer aspiration pneumonia from other natural causes.

Educate Families About End-of-Life Care

Healthcare providers are instructed to encourage patients’ families to adhere to the following established guidelines for hospice patients with regard to hydration and nutrition near the end-of-life:

  • Provide small sips of water or liquids, ice chips, hard candy or significantly small amounts of food with a spoon if the patient is still able to eat and/or drink. Adhere to signs from the patient for when to stop.
  • If a patient is no longer able to drink, maintain moisture of their mouth and lips with swabs, a wet washcloth, lip balm or moisturizers.
  • Encourage family members to offer alternative forms of nourishment such as engaging conversation, loving touch, music, poetry, humor, visits from pets, gentle massages, reading, prayers or other behaviors of compassion and love.

References

Teno, J., Meltzer, D. O., Mitchell, S. L., Fulton, A. T., Gozalo, P., & Mor, V. (2014). Type of attending physician influenced feeding tube insertions for hospitalized elderly people with severe dementia. Health Affairs, 33(4), 675-82. Retrieved from https://www.healthaffairs.org/doi/10.1377/hlthaff.2013.1248


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21/Jan/2021

Hospice is designed to foster quality of life with an emphasis on pain and symptom management. The deterioration of the skin that is detected from pressure ulcers or other wounds is a sign that the systems of the body are diminishing, and even completely breaking down.

Even when nearing the end of life, effective wound care can significantly influence comfort physically, psychologically and emotionally.  Wounds tend to ignite feelings of fear, hostility and even suspicion of negligence.  Inadequate care, or a lack of care for wounds can be extremely detrimental to the patient, and furthermore, negatively affect the experience of the family  throughout the very difficult time of losing a loved one.

Hospice Patients and Bedsores

Pressure ulcers, which are also known as bedsores, are very common among hospice patients, with over 40% of them experiencing them. Despite insistent preventive measures, and usually as a result of diminished muscle, cell, and immune function, among other factors, severely ill patients experience compromised response to healing.  For these patients, the development of bedsores may be a visual biological indicator that their severe illness has overwhelmed the body and it is important to note that the breakdown of skin is not fully preventable or treatable.

It is a possibility that once bedsores develop in terminally ill patients, family members may see this as a failure of the interdisciplinary team or the family caregivers themselves to provide adequate care.  Furthermore, their response, oftentimes being emotional, can lead to demands that are jeopardizing to the patient’s plan of care that is rooted in comfort.

Nonetheless, attempting to prevent and treat these concerns cannot get in the way of the hospice tenet of providing comfort-based care.  Research shows that comfort should overrule preventive measures in situations where advanced illness causes patients to be more comfortable in a particular position.  If the hospice interdisciplinary team determines that regularly scheduled patient movements increase their pain, these movements may be suspended.

Other Wounds Common in Hospice

Since hospice teams care for such an extensive variety of patients and conditions, there is an equally wide variety of wound types that they encounter, such as arterial insufficiency wounds, diabetic ulcers, venous ulcers, and tumors or fungating lesions.

Risk Factor Evaluation and Preventive Measures

Upon admission, conducting a comprehensive risk assessment is crucial, and needs to include a check of the patient’s entire body.  Bedsores are caused by both internal and external factors, including the lack of mobility, cognitive function deficiency, an  inability to verbalize discomfort or sensations like numbness, chronic sickness, aging and poor nourishment.

After the risk factors have been identified, the best practice is to prevent wounds from developing in the first place.  Measures for prevention include, but are not limited to consistently inspecting the skin of the patient and observing for appropriate moisture maintenance.  Also, suitable positioning, proper techniques for transfer, and nutrition are crucial with regard to the patient’s comfort.

Avoid pressure on the heels and bony prominences of the body, and use positioning devices whenever feasible. As always, remember to document the condition of the skin after assessment.

Staging (Categorizing) Wounds

The National Pressure Advisory Panel established the following wound stages, (NPIAP, 2017):

  • Stage I—Non-blanchable erythema of intact skin: Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate a deep tissue wound. 
  • Stage II—Partial-thickness skin loss with exposed dermis: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 
  • Stage III—Full-thickness skin loss: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable wound. 
  • Stage IV—Full-thickness skin and tissue loss: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable wound. 
  • Deep-Tissue Injury—Persistent non-blanchable deep red, maroon or purple discoloration: Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness wound (Unstageable, Stage 3 or Stage 4). Do not use deep tissue wound to describe vascular, traumatic, neuropathic, or dermatologic conditions. 
  • Unstageable—Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 wound will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 

Basic Principles of Wound Care

It is imperative to first establish an effective plan for wound care that includes determining the prognosis of the patient, their condition and the potential they have for their wound(s) to heal. For example, it would be fitting to have a less aggressive approach for a patient nearing end-of-life, or when it is clearly displayed that it is not realistic they will heal.

 

Setting appropriate goals that are determined by the prognosis, condition and potential for healing is essential, and within hospice care, these goals might include:

  • Prevention of complications with wounds (i.e. infection or odor)
  • Prevention of further skin breakdown
  • Minimization of harmful effects on the patient’s overall status as a result of wound(s) 

During the process of creating patients’ care plans, it is imperative to consider, and furthermore, incorporate their condition and their wishes.  This plan needs to be re-assessed regularly (typically biweekly) to ensure that it is still appropriate for the patient.  When a wound does not heal it does not always mean that other methods or treatments are necessarily more fitting, or that the interdisciplinary team should try all other treatment options.  The team should rather work to differentiate the plan to utilize the most appropriate options for that given patient based on their condition and wishes at that given time.

A standard plan for wound care will include the following:

  • Cleaning the wound of debris
  • Possibly debridement
  • Absorption of any excess exudate
  • Promotion of healing
  • Treatment of infection
  • Minimization of any discomfort

When a patient is in hospice care, wounds can be significantly stressful for the patient and family with regard to the associated pain, appearance, odor and furthermore the perceived implications of wounds. To maintain the goal of hospice of comfort-focused care, the interdisciplinary hospice team needs to function with diligence and detail to assess and document wounds and any changes to the patient’s condition while also conducting appropriate methods for prevention, and establishing and updating the care plan in consideration of the patient’s needs and wishes.

By decreasing the incidence and intensity of wounds and diminishing their impact, the hospice team provides an improved quality of life, and fosters an environment that allows for a peaceful death experience for both the patient and their loved ones.

References

The National Pressure Injury Advisory Panel. (2017). NPIAP pressure injury stages. Retrieved from https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf


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21/Jan/2021

Research has shown that a great majority of patients desire to know the truth about their condition, (Buckman & Kason, 1992). When patients are not provided with this information they report feeling alone and abandoned. The challenge is for health care providers to take the time to have these important conversations with patients and their families, as well as consistently provide updates to statuses, given that today’s environment often leaves clinicians constrained with regard to their time, (Kinzbrunner & Policzer, 2011). 

Healthcare providers have the opportunity to offer a precious and invaluable gift to patients and their families by discussing the patient’s options near the end-of-life, while still allowing the patient to enjoy quality of life.  A patient who is informed, and has an understanding of the options they have along with what hospice care can provide will have a stronger sense of control in their situation.

Similar to evaluating the health history of a patient or facilitating a physical, introducing pertinent end-of-life conversations with patients is an attainable skill that can be learned.  When done so effectively and thoughtfully, these discussions allow for stronger relationships between physicians and their patients, and improve the chances that patients will decide the most optimal treatment options, including hospice care.

Obstacles Within Talking About Death

  • Worry with regard to the patient’s reaction:  Regardless of the fact that patients want to know the truth about their conditions, they might have a strong emotional reaction or physical outburst initially related to the thought of having limited choices, a loss of control, a deteriorating lifestyle, changes in their image of self, and ultimately losing their life, (Kinzbrunner & Policzer, 2011).  Although these more intense reactions might trigger discomfort for the provider, properly preparing for the conversation along with specific consideration, or even empathy for the patient’s perspective will help to deescalate the situation.
  • Worry with regard to the provider’s reaction:  The provider may be concerned about appropriately responding to a patient’s anger, anxiety or sorrow.
  • Idea that the provider won’t be able to “do enough”:  Providers can even strengthen the relationship with the patient through exhibiting compassion and honesty while recognizing their own thoughts and feelings regarding the decline of a patient notwithstanding all efforts.  Discussing the options for end-of-life care is the next practical step in the continuum of care for the patient.
  • Leading such discussions triggers anxiety:  This obstacle is the easiest to conquer when the provider takes the time to become informed on how to effectively conduct end-of-life conversations thoughtfully and with compassion and empathy.  This learned skill will not only assist patients in making informed decisions, but also ease the discomfort of the provider.

 

SPIKES has six pragmatic aspects:

In case a person is diagnosed with a terminal illness, or is approaching death and is unable to communicate for themselves, end-of-life experts recommend that the following steps be taken proactively to ensure that the patient’s wishes are actually acknowledged and executed.

  • Setting – Decide on a private setting where you can sit in person with the patient and their loved one.  If the patient does not speak the same language as you, depend on a professional interpreter as opposed to a family member.  
  • Perception – Gauge the perception of the patient by asking how much they know, perceive or suspect before commencing the conversation.
  • Invitation – Discreetly invite the patient to provide information about their willingness to receive more information, by asking if they want to discuss test outcomes, treatments, etc. If the patient does not respond favorably, recommend that you try having the discussion at another time, possibly later that day or the next, and then make sure to follow up with them at the decided time.
  • Knowledge – Provide information directly and concisely, and once you have opened the discussion, stop talking in order to listen to the patient’s responses, thoughts and emotions.
  • Empathy – Acknowledge, and identify with the patient’s emotional reaction in a compassionate and kind way that suggests you not only understand, but appreciate their response and are genuinely concerned about their future as well.
  • Summation – Summarize the information and recommend they consider hospice care.

“SPIKE” Your Communication Skills and Your Confidence

As you follow the SPIKES system, you can increase your ability to facilitate effective discussions about end-of-life treatments and embracing hospice, (Buckman & Kason, 1992).

This will help you assess:

  • A patient’s understanding about their condition
  • A patient’s readiness to discuss end-of-life overall
  • The optimal way to adjust to a given patient’s response
  • The significant value of both silence and observation
  • How best to interpret a patient’s reaction, regardless of its appropriateness
  • How to inform your patients in a way that exhibits empathy
  • The role hospice care can play in maintaining hope, comfort and dignity

The Role Hospice Plays

Hospice plays an essential part with regard to the satisfaction that a patient and their family experiences at the end-of-life. Optimal hospice care is supplied for months, as opposed to weeks or days. Hospice care can assist in managing pain and symptoms, providing comfort, and addressing the spiritual and emotional needs of the patient and their family when intensity and/or side effects of treatment start to surpass any anticipated advantages.

Hospice care provides patients a sort of gift of time, enabling them to visit with loved ones, enjoy time outdoors, experience family milestones and to get affairs organized.

References

Buckman, R. & Kason, Y. (1992). How to break bad news: A guide for health care professionals. The Johns Hopkins University Press.

Kinzbrunner, B. M. & Policzer, J. (2011). End-of-life-care: A practical guide. McGraw Hill Professional.

Baile, W. F., Buckman, R., Lenzi, R., Glober, G., Beale, E. A., & Kudelka, A. P. (2000). SPIKES – A six step protocol for delivering bad news: Application to the patient with cancer. The Oncologist, 5(4), 302-311. https://doi.org/10.1634/theoncologist.5-4-302.


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21/Jan/2021

In an article published in the Journal of Clinical Oncology, the authors provide a review of relevant research with regard to end-of-life care for cancer patients, and they identify the ways that hospice care assists patients with advanced cancer and their loved ones who become caregivers. Ways in which hospice care can improve are also highlighted.

Priorities for Cancer Patients at the End-of-Life

The researchers observe that several studies have sought to explore the priorities of patients with advanced cancer and that of their caregiver for end-of-life care.  Some of the most commonly indicated priorities were related to the following:

  • Pain and symptom management
  • Feeling well enough to spend time with loved ones
  • Dealing with matters of business and legacy that had yet to be taken care of

As a result, the researchers state that “hospice care services have grown rapidly to support families and communities to care for people at home (including in skilled nursing facilities) through excellence in physical symptom control, psychological support, spiritual care, and support for caregivers.”

Mitigating the Burden of Symptoms

According to the research, hospice care allows for improvement of symptom management in issues that are commonly expected at the end-of-life. Symptom mitigation for advanced cancer patients nearing the end-of-life often involves addressing one or more of the following common symptoms:

  • Pain
  • Fatigue
  • Breathlessness
  • Delirium

The inability to feel pain was identified by the article as commonly the priority for patients and their loved ones over any other symptom. The evidence suggests that hospice care offers superior pain management to patients. Furthermore, it is noted that another priority symptom, delirium, which includes changes in cognitive function, illusions from hallucinating, and disruptions of sleep and wake cycles, can be treated with excellent nursing care.  Nurses can treat reversible causes, assist in orienting the patient, and provide appropriate hydration and nourishment.

Optimal Integration within End-of-Life Care

The researchers encourage practitioners to explain the prognosis of rapidly declining advanced cancer patients with them, and refer them to hospice services. Optimal end-of-life care for cancer patients, as noted by the article includes:

  • Every Health Professional Having Competency in Core End-of-Life Care Skills:  This consists of identifying the end-of-life status, understanding the key tenets of symptom management and interdisciplinary care, conducting patient-centered, effective communication and shared decision-making, executing excellent clinical skills in thorough bedside evaluation, and engaging with empathy and compassion.
  • Care from a Team-Based Approach:  The article explains that patients tend to be more likely to express their concerns and disclose information about more issues when an interdisciplinary team is providing care and since the patient-identified needs are extensive at the end-of-life, multiple health clinicians working collectively is essential to accomplish the most optimal outcomes for the patient.
  • Collaboration and Communication Between Hospice and Other Care Providers:  Most advanced cancer patients either change locations for care or are admitted to a hospital near the end-of-life, and therefore, effective communication between all involved providers is imperative. Despite consistently improving electronic medical records, the challenge still persists for all clinical teams to be aware of the communication that each care provider has with the patient and their family.

Support for Caregivers

A key aspect of hospice care is the support provided to caregivers, and although research on the topic is limited, evidence suggests that the most effective support for caregivers results in: 

  • Need for information and education being better met
  • Decreased rates of depression 
  • Improved ability to move forward with their own life after the death of their loved one

 In conclusion, the authors state, “Hospice provides patients with the potential for a better quality of life, improved symptom control, and more time away from inpatient care.” Furthermore, since most of the care for advanced cancer patients becomes the responsibility of caregivers, any additional support provided to them while acting in the caregiver role will likely be of significant advantage.

References

Currow, D. C., Agar, M. R., & Phillips, J. L. (2020). Role of hospice care at the end of life for people with cancer. Journal of Clinical Oncology, 38(9), 937-943. https://doi.org/10.1200/JCO.18.02235.


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21/Jan/2021

Dying is a natural process accompanied by declines in function, including neurocognitive, cardiovascular, respiratory, and muscular function.  This process was examined by researchers with regard to cancer patients, and their findings are outlined in this article.

The process of dying varies greatly, and can last up to several weeks in some cases. Actively dying or forthcoming death constitutes the last week of life, and has distinctive clinical signs that are detailed in this article.

The expression of clinical signs differs significantly among patients, but the more of these clinical signs that are shown within an individual, the more likely death is near.

Signs of Active Dying

The determination of a patient transitioning to imminent death is important, so that clinicians can help educate patients and families about the natural dying process.  Furthermore, this helps to inform their necessary decision-making as well as prepare the patient and family for death as much as possible.

Additionally, the care individualized plan is to be updated in order to reflect any changes in the patient’s status, and should include any necessary clinical visits. Please note that a higher level of care may be necessary in specific circumstances of crisis, or symptoms that are not being controlled by initial treatments.

The chart below shows median times that were identified in a study with cancer patients but can be generalized to other causes of death (i.e. heart disease, advanced lung disease, sepsis, and dementia). The following list is not exhaustive but includes some of the more common symptoms.

Days Before Death Clinical Signs
7+ Peripheral edema, delirium, dysphagia of solids, decreased speech, cool/cold extremities
4-6 Abnormal vitals, decreased level of consciousness, dysphagia of liquids
2-3PPS 20% or less, peripheral cyanosis, decreased response to visual stimuli, drooping of the nasolabial fold, hyperextension of the neck, Cheyne-Stokes breathing, nonreactive pupils, decreased response to verbal stimuli
Less than 2Death rattle, apnea, respiration with mandibular movement, decreased urine output, pulselessness of radial artery, inability to close eyelids, grunting of vocal cords, fever

Link Between Clinical Signs of Dying and Impending Death

There is a direct relationship between the amount of clinical signs of dying and death:

  • Patients with 2 clinical signs of dying had a 40% chance of dying
  • Patients with 8 clinical signs of dying had more than a 80% chance of dying

The research showed that the more existing clinical signs of death there are, there is a need for an update to the care plan which should include the appropriate interdisciplinary visits.  Ultimately, the process of a natural death results in clinical signs of dying where the more signs that are present increases the likelihood of death.

Involvement of Hospice Interdisciplinary Teams During Clinical Signs of Dying

When clinical signs of dying arise, the hospice interdisciplinary team commences an update to the care plan that will include:

  • Updating the appropriate interdisciplinary team visits
  • Education on the dying process for the patient and family
  • Adjustments to or implementation of medications
  • Ensure that the appropriate medical equipment is in place 

Below, the hospice team roles are described, as they each provide assistance and support in ways that are specific to their discipline and training.

Nurse/nurse practitioner/physician:

  • Discussion regarding the cessation of non-advantageous or troublesome treatments
  • Assure medications and necessary equipment are available to manage symptoms
  • Provide education to the family on utilization of equipment, and explain physiologic changes they may be able to recognize that are associated with the dying process

Social worker/spiritual care coordinator/chaplain:

  • Assist patients and families with exploring and expressing their feelings and navigating their relationships
  • Actively participate in the review of life, including the act of searching for meaningful contributions
  • Facilitate life closure, including forgiveness, addressing regrets, being able to say goodbye, and trying to find acceptance with regard to ongoing losses and death overall

Hospice aides/CNAs are responsible for recognizing the clinical signs of death to then communicate them to the rest of the interdisciplinary team, as well as supporting the patient and family through the dying process in any way they can.

References

Hui, D., Santos, R., Chisholm, G., Bansal, S., Souza Crovador, C., & Bruera, E. (2015). Bedside clinical signs associated with impending death in patients with advanced cancer: Preliminary findings of a prospective, longitudinal cohort study. American Cancer Society Journals, 121 (6), 960-67. https://doi.org/10.1002/cncr.29048

Hui, D., Santos, R., Chisholm, G., Bansal, S., Buosi Silva, T., Kilgore, K., Souza Crovador, C., Yu, X., Swartz, M. D., Perez-Cruz, P. E., Almeida Leite, R., Salete de Angelis Nascimiento, M., Reddy, S., Seriaco, F., Yennu, S., Paiva, C. E., Dev, R., Hall, S., Fajardo, J., & Bruera, E. (2014). Clinical signs of impending death in cancer patients. The Oncologist, 19(6), 681-87. 10.1634/theoncologist.2013-0457


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Precious Hospice partners with patients, families and caregivers to lovingly provide skilled care to the terminally ill. Our multi-disciplinary team is committed to patient pain and symptom management, and the emotional, spiritual and social support for patient and family.

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