Misconceptions of Hospice Care

Unfortunately, the word hospice in itself is surrounded by both mystery and misconception.  Often misunderstood, hospice has been viewed as a place where patients go to die.  It has been assumed that all treatment is stopped, and a DNR and absolute certainty of the diagnosis are required.

The reality of a progressive and highly symptomatic terminal illness leaves most patients and healthcare providers uncomfortable to varying degrees.  The intent of the Medicare hospice benefit is also oftentimes misunderstood.

Realities of Hospice Care

The purpose of the Medicare hospice benefit is to provide all healthcare needs to a vulnerable population, while assisting in preventing overuse of the emergency departments and hospitals nearing the death of a patient. The reality is that hospice is a philosophy of care designed for patients who are suffering from terminal illnesses and who are entering the last six months of their life. Hospice is not actually a place, but instead, it is a set of services offered to patients in whatever setting or space that they call home.

As opposed to overly aggressive, disease-modifying therapy, which too often comes at the expense of quality of life, hospice patients have made the decision to pursue a symptom-oriented approach to care.  Hospice care is provided by an interdisciplinary team with the patient and their loved ones at the center of its focus.  The priority is expert management of distressing the physical, emotional and spiritual symptoms a patient is experiencing.

Hospice provides all of the medications and services related to the terminal prognosis, including home visits from a physician for the management of the patient’s symptoms.  A patient who has opted to receive hospice care has multiple visits each week from various experts in different disciplines. The goals of care are addressed and symptoms are managed appropriately.  After the patient dies, no matter the length of their enrollment, the family members are provided access to hospice bereavement services for at least a year.

Become Aware of Your Patient’s Background

In an article published by NPR in 2015, Robert Siegel stated that according to the Department of Veteran Affairs, half of men that die are military veterans (Lawrence, Q., 2015).  The unfortunate reality that impacts this significant figure is that several healthcare providers that are caring for patients with severe, progressive, or terminal illness are not aware of their patients’ military background.  Furthermore, providers do not always recognize that when symptoms progress, and treatments are no longer successful, the uncontrolled pain, anger, and/or nightmares, may be delayed symptoms of, or overall undiagnosed post-traumatic stress disorder (PTSD) which is so very common among veterans. 

In a Health Affairs article published in 2017, researchers found that the strategic efforts of the Veterans Administration to improve the quality of end-of-life care, by increasing hospice use, have been effective (Miller, S. C., et al, 2017).  Although these findings are significant, it is essential to understand the implications that are inevitable when caring for veterans, as “caring for vets isn’t always the same as caring for others: as veterans approach the end of life, old traumas can resurface or appear for the first time,” (Lawrence, Q., 2015). 

The Unique Needs of Veterans are Treated in Hospice Care

Hospice care providers are trained to understand the unique end-of-life needs of veterans, and provide guidance to them with the emphasis on a more peaceful transition.  As experiences from the past often resurface near the end of life, this becomes especially essential for veterans who have experienced combat service or other violent trauma.

Given the unique needs of veterans, the National Hospice and Palliative Care Organization (NHPCO) and the Department of Veterans Affairs (VA) have initiated a pioneer project entitled, “We Honor Veterans” which focuses on respectful inquiry, compassionate listening and thankful acknowledgement of veterans.  Precious Hospice is a contributing partner in “We Honor Veterans,” and we are recognized for our dedication to those who have served our country.

The Physical, Psychological, and Emotional Impact of Military Service

Serving in a war takes a toll on military personnel both physically and emotionally.  This impact includes but is not limited to diseases, disabilities and illnesses, which can create difficult challenges in providing end-of-life care.  Depending on the war(s) in which veterans have served, they may have been exposed to ionizing radiation, Agent Orange, open-air burn pits, battlefield transfusions, below-freezing temperatures and infectious diseases.  Furthermore, this intense exposure puts them at an increased risk for several types of cancer, type 2 diabetes, kidney disease, heart disease, hepatitis C, respiratory illnesses, malaria, TB and more.  Additionally, veterans can also suffer from co-morbidities such as post traumatic stress disorder (PTSD), depression, anxiety, drug addiction, alcoholism, and mental illness.

Along with the physical and psychological conditions that veterans endure, emotional concerns may arise, like the feeling that they need to purge themselves of memories by speaking with their family members about their military experience, sometimes for the very first time. Veterans also commonly are worried about the well-being of their families, in terms of how they will manage after the veteran dies.

Essential Elements of Hospice Care for Veterans:

• Streamlined referral and admission processes
• Thorough understanding of the Veterans Administration (VA) system, and how to identify and access all benefit options available for veterans you are serving 
• Coverage of hospice care for veterans via the VA, TRICARE, Medicare, Medicaid, private insurance and other forms of reimbursement
• Coordination of care with local VA medical staff, including combined visits when appropriate
• Staff is trained to function as direct contacts for communication, and primary educational sources to the VA and other local veteran organizations
• Referrals for additional community services when necessary
• Bereavement support, including grief and loss programs, support groups and memorial services, for the loved ones of veterans
• Recognition and celebration of important events such as Veteran’s Day and military anniversaries

If you have a seriously ill patient who is also a military veteran under your care, talk to the patient and their family about whether they are utilizing or have any questions or concerns regarding their VA benefits.  Working with a hospice provider can help the family navigate the VA system, and help the patient feel both respected and listened to as they are nearing the end of life. 

References

Lawrence, Q. (2015). End of life care can be different for veterans. National Public Radio (NPR). Retrieved from https://www.npr.org/2015/01/28/382218316/end-of-life-care-can-be-different-for-veterans

Miller, S. C., Intrator, O., Scott, W., Shreve, S. T., Phibbs, C. S., Kinosian, B., Allman, R. M., & Edes, T. E. (2017). Increasing veterans’ hospice use: The veterans health administration’s focus on improving end-of-life care. Health Affairs, 36(7), 1274-82. Retrieved from https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2017.0173

Spiritual care is valuable at any time, for any patient. As described in an article published by the British Association of Critical Care Nurses, “people of all faiths, and no faith, can benefit from a supportive presence who can take the time to help them find meaning and purpose in their suffering,” (Timmons, F., et al, 2015).  At Precious, we’ve learned how it is particularly essential for hospice patients as they struggle with apprehensions about nearing the end-of-life.

Social workers make a big difference by bringing psychosocial and emotional support to patients and families, and it is as important to Precious to also have a Spiritual Care Coordinator as a vital member of the interdisciplinary team to provide spiritual support. 

Three Ways to Assist with Spiritual Guidance for Your Patients:

• Ask your patients about their faith, or lack thereof.  If they belong to a religious community or congregation, encourage them to connect with fellow members and the leader(s) of their communities.  At times, patients and families have hesitations, as they do not want to be a  burden to others, and therefore might need encouragement to reach out.
• First, learn a little bit about your patient’s, and/or their family’s, beliefs and interests.  Then, look in the bookstore or online for patient-oriented books on death and dying to recommend appropriately.  There is an abundance of books on death and dying, from the humorous example of “Can We Talk About Something More Pleasant” by Roz Chast to the very deeply philosophical “Advice on Dying” by the Dalai Lama, plus many others in between.
• Ask a Precious care team manager about connecting with the Spiritual Care Coordinator.

Spiritual Care Coordinators at Precious 

Specialized spiritual care is an essential responsibility of the Precious interdisciplinary care team, specifically our Spiritual Care Coordinators. Precious SCCs are always available to support patients and grieving families with counseling appropriate to any faiths—and no faith at all.

Our SCCs help patients and their loved ones cope with grief and loss. They are there for families for 13 months after a death, and can provide one-on-one support, support groups as well as grief education.

References

Timmons, F., Naughton, M. T., Plakas, S., & Pesut, B. (2015). Supporting patients’ and families’ religious and spiritual needs in ICU – can we do more? British Association of Critical Care Nurses, 20(3). Retrieved from https://onlinelibrary.wiley.com/doi/epdf/10.1111/nicc.12177

January Employee of the Month:

Elaine Wilson, Office Manager (Atlanta)

Precious Healthcare is proud to announce that Elaine Wilson, our Office Manager, is recognized as our January Employee of the Month!  Elaine not only is diligent in maintaining the operations of the office, but consistently shows her commitment to Precious’ mission of loving care through life’s precious moments.  With her positive spirit and hardworking nature, she serves as the glue that keeps the office together.  Many thanks to Elaine for all she does to contribute to the efforts of Precious to care for patients and their loved ones during life’s most precious times!

Covid-19 Update:

The COVID-19 pandemic  presents a challenging and uncertain time for patients and their families and healthcare providers.

Precious Healthcare is dedicated to providing current, clear and concise information on Covid-19, its effects, and our organizational response to the current situation as it evolves.

We are committed to offering the safest care possible for our patients, families, staff and volunteers, by taking all necessary precautions that are outlined by the Centers for Disease Control (CDC).  If you have any questions regarding Covid-19 guidelines, please call our office at 470-878-5051 or visit https://www.cdc.gov/coronavirus/2019-nCoV/index.html

Heart 2 Heart

Precious Healthcare presents our newest LIVE stream, “Heart 2 Heart.”  This streaming will feature some of our most prominent healthcare and community leaders from all over the world. These civic leaders will be discussing their levels of healthcare expertise and answering some of your most frequently asked questions pertaining to health and wellness. With this, we hope to cover all topics healthcare-related, and give our listeners and viewers the opportunity to interact virtually with our healthcare and community leaders. 

Heart 2 Heart will take place every Thursday evening.

The live stream will be accessible via Youtube, Zoom, Instagram Live, and Facebook Live.

Discussion Topics include but are not limited to best COVID safety practices, healthcare strategies and initiatives, maintaining work-life balance, mental, and physical health, and community leadership.

We are excited to share with you, so tune in!

What are best practices for terminally ill patients who frequent the emergency department? What do patients, families, hospitals and payers want? What is your role? What is the role of hospice?

The Hospital Readmissions Reduction Program is a Medicare value-based purchasing program that was developed by the Centers for Medicare & Medicaid Services (CMS) for a reason. Consider the fact that one third of Medicare patients are readmitted within 90 days, and about 20% of Medicare patients are readmitted within 30 days. At Precious Hospice, we can admit patients whose status are appropriate for hospice directly from the emergency department.

Partnering with Precious to Achieve Key Goals

When a hospital partners with Precious, patients with end-of-life needs get the appropriate care, and the hospital can achieve the following objectives: 

• Reduced ED overcrowding, readmissions and observation periods
• Improved ED throughput and bed cycling
• Seamless transitions to post-acute care
• Improved family-satisfaction metrics

Hospitals are reprimanded for decreased “core measure” quality outcomes and reduced patient/family satisfaction scores.  Furthermore, seriously ill patients do not want to readmit. When surveyed, their preferences and main areas of concern include pain and symptom management, improvement of their relationships with family rather than an increased burden on their loved ones, not lengthening the dying process, and the development and maintenance of a sense of control.  Unfortunately, readmissions are often due to a lack of planning regarding discharge or inadequate community-based or outpatient care, in addition to severely progressive illness.  Patients who are readmitted typically do not have follow-up plans, and oftentimes are not able to voice their diagnosis or medications. Once these types of situations are identified, however, such issues are easy to mitigate.

Indicators that a Patient Might be Eligible for Hospice Care:

• Frequent readmissions to the emergency department, hospital or intensive care unit
• Ongoing symptoms continue regardless of suitable, quality treatment
• Decline of functional abilities
• Decrease and/or consistent declining of renal function
• The utilization of inotropes
• Goals of the patient are centered in their quality of life
• Response to the question: “Would you be surprised if this patient died in the next 6–12 months?” is NO

When a patient is referred to hospice care as soon as it is fit, patients are able to receive the clinical and psychosocial care needed to control their pain and symptoms, and ultimately improve their quality of life. The interdisciplinary team provides care in the comfort of the patient’s home, and continuous care is provided when medically necessary, keeping the patient from having to go to the hospital.

Strong indicators that your patient could benefit from hospice care are an increased use of emergency department and hospital services, as well as increased burden of symptoms along with decreased overall function.   A way to evaluate this is to use your best judgment to answer the following question:

“Would I be surprised if in the next six months this patient was no longer with us?”

Your answer to the above question will further determine the appropriateness of hospice services for the given patient.

Pressure on Emergency Department (ED) Providers 

Emergency Department providers ideally should feel empowered and honored to implement treatment options for patients that they have recognized as near the end of life.  However, quality metrics such as ED throughput, hospital readmissions and others are placing a tremendous amount of stress and pressure on ED practitioners, as well as the acute care system, to provide quick, efficient, and high quality care to their patients.

As people live longer and medical technology advances, EDs are seeing elderly patients with numerous, advanced, chronic illnesses that progress simultaneously, through the top treatments—until they don’t. The ED staff is then faced with uncontrolled pain, dyspnea, delirium and functional decline that are results from conditions like heart failure, COPD, vascular disease or any combination thereof progressing.  Dementia furthermore makes the situation more complex, especially if the goals of care and advance directives have yet to be conveyed. The patient becomes an ED frequent flyer, leading to difficulties with wait times, throughput, observation utilization, and boarding.

How to Offer Our Patients a Better Life

By determining the frequent flyer patients early in the ED and hospital cycles, and moreover, punctually referring them to hospice care, we can offer them better lives. They can be at home, wherever it is that they call home, and an interdisciplinary team will bring all the necessary clinical services to them.  With the elimination of panicked emergency calls, the quality of life improves. Their families receive support that they need, ED teams are able to focus on emergent care, and we are able to begin the process of breaking the cycle.

Is it possible to have your seriously or terminally ill patients live and die at home? Absolutely, and studies show that they receive more appropriate, and much less costly care that meets their needs and preferences near the end of life.

This can be largely credited to the expertise that a hospice provider possesses with regard to end-of-life care, where they are able to address pain and other symptom management while also tending to the spiritual and social-emotional needs of patients and families. 

Hospice Provides Education to Family Caregivers

In addition to supporting the patient and their family with high quality, professional care, hospice providers must also provide education to family caregivers, who often provide the majority of their loved one’s care.  Effective communication is essential. The interdisciplinary team and the family must concur on the goals of patient care so that everyone is on the same page.  The interdisciplinary team is present in the home and are able to see the layout, the areas the patient most often uses, and what tasks will fall on one or several of the family caregivers. The team will monitor the status of care for anything that might create a threat of harm to the patient.

Family homes are not typically designed to provide healthcare, and furthermore, caregivers may vary in number and ability, which also poses a challenge.  Each person involved must effectively communicate their questions and concerns to ensure the safety of the patient as in situations of slip-and-fall hazards or moving the patient safely, for example. Furthermore, when a family visitor offers to assist, the paradigm and expectations are already in place and allows for less of a chance for misunderstanding or to make a mistake that can lead to an injury.

Hospice Educated Families about Infection Control

When working with families and caregivers, an important aspect that is discussed is infectious disease.  Below are some of the infection control guidelines we expect caregivers to follow:

1. Maintain good personal hygiene

• Wash your body frequently
• Wash your hair at least twice a week
• Brush your teeth and rinse your mouth after each meal
• Trim your fingernails and toenails weekly
• Wear clean and laundered clothes
• Change dirty clothing and bedding anytime you notice any soiling

2. Wash your hands thoroughly and frequently

• Before preparing, eating or serving food
• After using the restroom, having contact with your own or another’s body fluids, and blowing or wiping your nose

       Best hand washing procedure:

1. Wet your hands with plenty of soap and warm water
2. Lather soap over your hands and wrists
3. Rub the palm of one hand over the back of the other, and rub them together several times, then repeat with the other hand
4. Interlace your fingers on both hands and rub them back and forth
5. Clean under your fingernails with a nail-brush or an orange stick
6. Rinse your hands thoroughly under warm running water
7. Thoroughly dry your hands and wrists 

3. Clean your household thoroughly

• Avoid any household clutter
• Thoroughly ventilate your home with fresh air
• Clean kitchen counters with a scouring powder
• Dust and vacuum at least weekly
• Mop the kitchen and bathroom floors at least weekly and anytime spills occur
• Clean inside the refrigerator with soap and water weekly 
• Add a teaspoon of bleach to each quart of water used for flower vases
• Wear gloves when cleaning any animal areas (i.e. birdcages, litter boxes, aquariums, etc.)

4. Clean contaminated household and medical equipment thoroughly

• Clean medical equipment as instructed by your interdisciplinary team
• Clean soap dishes, denture cups, etc., weekly
• Do not use the same sponges or cloths to clean the bathroom and kitchen
• Do not pour mop water into the kitchen sink
• Do not clean sponges or cloths in the kitchen sink
• Disinfect mops and sponges weekly by soaking in one part bleach to nine parts water for 5 minutes

5. Decrease your exposure to people with infectious diseases

• Avoid crowds as much as possible
• Avoid people who have been recently vaccinated
• Do not share food or drink with others

Covid-19 Update:

The COVID-19 pandemic presents a challenging and uncertain time for patients and their families and healthcare providers.

Precious Healthcare is dedicated to providing current, clear and concise information on Covid-19, its effects, and our organizational response to the current situation as it evolves.

We are committed to offering the safest care possible for our patients, families, staff and volunteers, by taking all necessary precautions that are outlined by the Centers for Disease Control (CDC).  If you have any questions regarding Covid-19 guidelines, please call our office at 470-878-5051 or visit https://www.cdc.gov/coronavirus/2019-nCoV/index.html.

Precious Gifts Holiday Toy Drive 2020 brought to you by Precious Healthcare and friends!

Thank you to all of the wonderful staff and volunteers that donated toys or their valuable time to make this very special event a success!  We were able to collect and deliver over 800 toys to children in our community!  We look forward to providing continued support to those who need it most.

December Employee of the Month:
John Mason, Community Relations Liaison

We want to extend a grand thank you to John Mason, our Community Relations Liaison, for all that he does!  John has been instrumental in various community outreach projects such as our Precious Gifts Holiday Toy Drive where we were able to provide over 800 toys to children in need, as well as our upcoming streaming series, Heart 2 Heart.  John is dedicated to the mission of Precious Healthcare and unwavering in his ambitions to help those in our communities learn about the precious care we offer.  Thank you John, for being a strong conduit between Precious Healthcare and the communities that we serve!

Heart 2 Heart

Precious Healthcare presents our newest LIVE stream, “Heart 2 Heart.”  This streaming will feature some of our most prominent healthcare and community leaders from all over the world.  These civic leaders will be discussing their levels of healthcare expertise and answering some of your most frequently asked questions pertaining to health and wellness.  With this, we hope to cover all topics healthcare-related, and give our listeners and viewers the opportunity to interact virtually with our healthcare and community leaders.

Heart 2 Heart will take place every Thursday evening from 7:00-7:20pm EST.

The live stream will be accessible via Youtube, Zoom, Instagram Live, and Facebook Live.

Discussion topics include but are not limited to best Covid-19 safety practices, healthcare strategies and initiatives, maintaining work-life balance, mental, and physical health, and community leadership.

We are excited to share with you, so tune in!