When Decision-Making Is Imperative: Advance Care Planning for Busy Practice Settings

Complex, chronically ill patients present an opportunity to discuss and implement hospice and palliative care. Many elderly patients who present to the ED and other busy practice settings are hospice-eligible because of functional decline and multi-morbidity. Key tools can quickly facilitate goals-of-care (GOC) conversations, advance care planning, and hospice referrals amid time constraints and high-acuity challenges.

1. When Decision-Making Is Imperative: Advance Care Planning for Busy Practice Settings

2. CME Provider Information Satisfactory Completion Learners must complete an evaluation form to receive a certificate of completion. You must participate in the entire activity as partial credit is not available. If you are seeking continuing education credit for a specialty not listed below, it is your responsibility to contact your licensing/ certification board to determine course eligibility for your licensing/certification requirement. Physicians In support of improving patient care, this activity has been planned and implemented by Amedco LLC and VITAS ® Healthcare. Amedco LLC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation Statement – Amedco LLC designates this live activity for a maximum of 1 AMA PRA Category 1 Credit TM . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

3. CE Provider Information VITAS Healthcare programs are provided CE credits for their Nurses/Social Workers and Nursing Home Administrators through: VITAS Healthcare Corporation of Florida, Inc./CE Broker Number: 50-2135. Approved By: Florida Board of Nursing/Florida Board of Nursing Home Administrators/Florida Board of Clinical Social Workers, Marriage and Family Therapy & Mental Health Counseling.  VITAS Healthcare programs in Illinois are provided CE credit for their Nursing Home Administrators and Respiratory Therapists through: VITAS Healthcare Corporation of Illinois, Inc./8525 West 183 Street, Tinley Park, IL 60487/NHA CE Provider Number: 139000207/RT CE Provider Number: 195000028/Approved By the Illinois Division of Profession Regulation for: Licensed Nursing Home Administrators and Illinois Respiratory Care Practitioner. VITAS Healthcare, #1222, is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved as ACE providers. State and provincial regulatory boards have the final authority to determine whether an individual course may be accepted for continuing education credit. VITAS Healthcare maintains responsibility for this course. ACE provider approval period: 06/06/2024 – 06/06/2027. Social workers completing this course receive 1.0 ethics continuing education credits. VITAS Healthcare Corporation of California, 310 Commerce, Suite 200, Irvine, CA 92602. Provider approved by the California Board of Registered Nursing, Provider Number 10517, expiring 01/31/2025. Exceptions to the above are as follows: AL: No NHAs, DE: No NHAs, DC: No NHAs, GA: No NHAs, KS: No NHAs, NJ: No NHAs, OH: No NHAs, PA: No NHAs, TX: No NHAs, VA: No NHAs, WI: No NHAs and Nurses are not required – RT only receive CE Credit in Illinois.

4. Objectives After this presentation, learners should be able to: Identify the role and benefits of palliative care and hospice in the care are continuum Know the elements of and how to implement a goals-of-care assessment Describe rapid palliative care assessment for busy practice settings Know how to leverage a goals of care assessment to drive patient care Understand the role that hospice providers (e.g., VITAS) can play in the continuum of care for seriously ill patients

5. Redefining the Care Continuum Medical decision-making is dichotomous where treatments are curative/life-prolonging or supportive/symptom-focused Inter-related goals where life-prolonging and supportive/symptom-focused can occur concomitantly. Benefits from ongoing dialogue around disease progression despite optimal medical management Curative Onset of illness Death Palliative Curative Onset of illness Death Palliative

6. Goals of Care: Opportunities for Engagement Discusses, understands and plans for future healthcare decisions incorporating one’s wishes and values Disease trajectory represents common causes of death (cancer, advanced lung and cardiac diseases, dementia, etc.) Conversations should occur throughout the natural history of serious illness, see below Index presentation and hospitalization introduce natural disease history and concept of advance care plan Acute exacerbations including ED visits and hospitalizations; ongoing disease education and help to complete an ACP Annual Wellness Visit Assists in timely transition to hospice Quality of Life

7. End-of-life discussions: Give back control to patients and offer hope ARE NOT associated with: – Physiological distress compared to those who do not have end-of-life discussions ARE associated with: 2x increased likelihood of accepting a terminal diagnosis 3x more likely to complete DNR – Almost 2x as likely to complete a power of attorney compared to patients who do not have end-of-life discussions McGill Psychological Subscale* Total Yes No P value adjusted least square means (SE) Sample “Depressed” 7.4 (2.9) 7.3 (0.2) 7.4 (0.2) 0.79 “Nervous or worried” 6.9 (3.2) 6.5 (0.3) 7.0 (0.3) 0.19 “Sad” 7.2 (3.0) 7.3 (0.2) 7.2 (0.2) 0.79 Acceptance, preferences and Total Yes No AOR (95% CI) planning, N (%) Sample Accepts illness is terminal 125 (37.7) 65 (52.9) 60 (28.7) 2.19 (1.40-3.43) * Against death in ICU 118 (35.5) 60 (48.8) 58 (27.8) 2.13 (1.35-3.37) * Completed DNR order 134 (41.1) 75 (63.0) 59 (28.5) 3.12 (1.98-4.90) * Completed living will, durable 181 (55.2) 86 (71.7) 95 (46.1) 1.96 (1.25-3.07) ** power of attorney, or healthcare proxy *Subscales of the McGill Quality-of-Life Questionnaire (scale 0-10) where 0 is undesirable and 10 is desirable. N = 332 *value < 0.001 **P value = 0.003 End-of-Life Discussions Align Care With Patients’ Wishes and Values Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment.  JAMA , 300(14), 1665-1673.

8. End-of-life discussions: Changed the care patients received; care was associated with a better quality of life and death Total Yes No AOR (95% CI) a ICU admissions 31 (9.3) 5 (4.1) 26 (12.4) 0.35 (0.14-0.90)* Ventilator use 25 (7.5) 2 (1.6) 23 (11.0) 0.26 (0.08-0.83)* Resuscitation 15 (4.5) 1 (0.8) 14 (6.7) 0.16 (0.03-0.80)* Out-patient hospice 173 (52.3)  80 (65.6) 93 (44.5)  1.65 (1.04-2.63) ** > 1 week  *P value = 0.02 **P value = 0.03 End-of-Life Discussions Align Treatments With Patients’ Wishes and Values Wright, A., et al. (2008). Associations Between End-of-Life Discussions, Patient Mental Health, Medical Care Near Death, and Caregiver Bereavement Adjustment.  JAMA , 300(14), 1665-1673. Reduced: ICU admissions by 65% Ventilator use by 74% Resuscitation by 84% Outpatient hospice care for > 1 week increased 1.6x compared to those without end-of-life discussions

9. Palliative Care in Busy Practice Settings ABIM Foundation. (2015). American College of Emergency Physicians. Choosing Wisely | Promoting Conversations between Providers and Patients. Retrieved from: https://www.choosingwisely.org/clinician-lists/american-college-emergency-physicians-delaying-palliative-and-hospice-care-services-in-emergency-department/ Lamba, S., & Quest, T. E. (2011). Hospice Care and the Emergency Department: Rules, Regulations, and Referrals. Annals of Emergency Medicine, 57(3), 282–290. https://doi.org/10.1016/j.annemergmed.201 The influx of medically complex, chronically ill patients presents an opportunity to enhance the role of palliative care and hospice Many elderly patients who present to the ED/hospital are hospice- eligible, usually because of functional decline and multi-morbidity ED is not designed for end-of-life (EOL) palliative discussions Time constraints and high-acuity make lengthy conversations difficult Palliative care in ED/hospital is changing ED palliative care specialists and specialized geriatric EDs are emerging

10. The Importance of Goals of Care Patients’ values are honored Symptoms are attended to quickly and effectively Patient and family maintain control of treatment plan Poorly defined goals can lead to: Unwanted treatments Inappropriate use of resources Undue suffering Miscommunication Clinicians establish GOC with patients daily Any team member can assess GOC

11. ACP Is Not About a Piece of Paper Advance care planning is about life philosophies, goals, preferences, priorities, family understanding, and support It is about preventing suffering for the patient’s family, as much as or more than, the patient by helping them see the road ahead Uses windows of opportunity to address different and changing aspects of a patient’s/family’s care goals over time

12. 4 months ago Presented to ED with fall with abrasions Patient : JR is an 88 y/o with advanced lung disease. He resides in an ALF and daughter lives locally and is decision-maker Medical History COPD for 20 years, 60-pack/ year smoking history, HTN, NIDDM diet controlled, PVD. Past history of severe COPD on O 2 , HTN, and dementia Symptoms Labored breathing at 28 BPM, O 2 sat of 88% 4L, wheeze, occasional cough, cachectic appearing, and is confused, picking at sheets and not following commands 2 months ago Observation stay for COPD exacerbation and delirium 6 months ago Hospitalized for severe COPD exacerbation with admission to ICU on BiPAP has been in SNF since D/C Typical Clinical Presentation SNF to ED Now Brought into the ED by ambulance from SNF for altered mental status and shortness of breath Treatments Disease-directed therapy with Spiriva, Advair, and chronic oxygen therapy. Receives some benefit from nebulizer and uses it “a few” times a day

13. Advance Care Planning in the Emergency Department Wang, D. H. (2017). Beyond Code Status: Palliative Care Begins in the Emergency Department. Annals of Emergency Medicine , 69(4), 437–443. https://doi.org/10.1016/j.annemergmed.2016.10.027 The ED has a unique opportunity to serve as a hub for unmet palliative care needs Palliative care and hospice referrals can reduce ED utilization and hospitalization by as much as 50% GOC discussions in ED with appropriate hospice and palliative referrals can benefit the patient and healthcare system Patients who have the opportunity to interact with hospice and palliative care have higher satisfaction scores This is a key opportunity to begin conversations around ACP and GOC

14. Advance Care Planning in Busy Practice Settings Busy practice settings like the ED and hospital are important settings where primary palliative care can be provided by any clinician to include: Facilitating basic GOC conversations Facilitating basic treatment decisions Providing basic pain and symptom management “Lack of time” is the most common reason cited by physicians for not engaging in these conversations

15. Two Components of Goals of Care Assessment First: Identify the patient’s prognosis The “surprise question” is the easiest and most predictive “Would I be surprised if the patient were to die in the next 12 months?” “Would it surprise me if the patient were to die in the next 6 months?” “Would it surprise me if the patient were to die during this admission?” Many times, a life-limiting illness or significant disease progression is diagnosed in the ED

16. Goals of Care Considerations Identify key practices to conduct a goals-of-care conversation Describe a protocol to elucidate goals of care Cure disease Prolong life Maintain or improve function Maintain or improve quality of life Relieve burdens, support loved ones Relieve suffering

17. Goals of Care Considerations (cont.) Accomplish personal milestones Attend important family events Go home Mend relationships Make peace with God Experience a good death Multiple goals often apply simultaneously Certain goals may be sacrificed to meet other goals with greater priority Goals change; this is expected, and ideally occurs gradually Explicitly include a goal of comfort from the very first encounter

18. Two Components of Goals of Care Assessment Second: Elicit the patient’s and family’s goals of care Patients and families are more capable of making decisions about treatment goals than about treatment interventions Patients and families desire honest, compassionate communication about prognosis and appropriate treatment options Feel comfortable making recommendations to patients and families

19. JR Case (cont.) JR was diagnosed with COPD exacerbation and treatment with nebulizers, oxygen, steroids, and antibiotics is started. Patient’s daughter is called and states that her father has had significant decline in the last year. He requires more help at home is completely dependent and spends more time in bed. Her goals for JR are for comfort, to have easy things treated, no heroic measures, and to try and stay out of the hospital. Disposition options for JR include: Admission Observation Return to SNF with DNH/DNR Return to SNF with hospice services

20. Goals of Care: Introduction Goals of care: Are personal Drive intervention choices May change over time GOC processes can be used at any time during a person’s illness

21. Goals of Care Patients can have several goals of care that at first glance, may seem contradictory: Communicate to find balance Curative and palliative paths can coexist Allows for some treatment to continue rather than changing the goal Goals may change Some take precedence The shift in focus of care: Is gradual and is an expected part of the continuum of medical care

22. Goals of Care and Advance Care Planning GOC and ACP constantly evolve with patients’ clinical status Multiple opportunities to address GOC and ACP throughout the disease process are impacted by: Prognosis Key healthcare transition points Disease severity Treatment options Patient’s wishes

23. GOC and ACP Early in Diagnosis When presenting a patient with a diagnosis of a serious/advanced illness, take the opportunity to address and document some basic and “easy” care goals The proxy “If you were ever unable to make decisions for yourself, who knows you the best and who would you want to make decisions for you?” The line in the sand “There are a lot of things that we doctors can do for you. Is there anything that you would find completely unacceptable?” Based on response, this may require clarification and further exploration

24. GOC and ACP as Disease Progresses Patients who progress through life-limiting illnesses often have undergone numerous surgical and medical interventions Wishes change based on: Illness course Past response to treatment Functional decline Symptom burden In an ideal situation, a GOC may have been established. However, a clinical change may present an opportunity to re-address: hospitalization, ED visit, ICU admission, rehab/skilled care, disease progression, new symptoms, inability to tolerate treatments, new goals

25. As functional status declines, so does prognosis The rate of decline affects prognosis Several validated scales can help measure functional status over time Several available performance tools. Here we cover: Basic ADL decline (3 out of 6) Palliative Performance Scale (PPS) ≤ 50% Spending >50 of waking hours lying or resting Disease-specific prognostication Functional Status Is an Important Element of Prognostication

26. Survival by Palliative Performance Score (PPS) at Acute-Care Hospital Masterson Creber , R., et al. (2019). Use of the Palliative Performance Scale to Estimate Survival Among Hospice Patients With Heart Failure. ESC Heart Failure , 6(2), 371-378. PPS Score Ambulation Activity and Evidence of Disease Self-Care Intake Conscious Level 60 Reduced Unable to do hobby/housework Significant disease Occasional assistance necessary Normal or reduced Full or confusion 50 Mainly sit/lie Unable to do any housework Extensive disease Considerable assistance required 40 Mainly in bed Unable to do most activities Extensive disease Mainly assistance Minimal to sips Full or drowsy +/- confusion 30 Totally bedbound Unable to do any activities Extensive disease Requires total care Mouth care only Patients with a PPS score of ≤ 50 are generally hospice-eligible; some patients with a higher PPS may also be eligible

27. Functional Decline Trajectory ADL Dependency and Disease-Related Complications Disease-related complications can support eligibility: Frequent ED use Recent hospitalization Recurrent hospitalizations Weight loss Prognosis of 6 mo. or less if illness runs its normal course Functional decline Increased symptom burden Disease-related complication; dependence in 5/6 ADLs Death Disease-related complication; dependence in 2/6 ADLs Disease-related complication; dependence in 1/6 ADLs Hospice-Eligible Dependence in 3/6 ADLs (bathing, dressing, feeding, continence, ambulation, transferring) Disease-related complication within last 6 months PPS ≤ 50%

28. ABCD Assessment Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html Covers physical and psychosocial domains If patient stabilizes, move to subacute assessment For patients who are acute, unstable, or critical: A A dvance care planning C C aregivers to consider Make the patient feel B etter B D ecision- making capacity D

29. ABCD Assessment (cont.) Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html A dvance Care Planning Feel B etter Rapid assessment and treatment of symptoms Dyspnea Delirium Pain Relief of critical/ unstable distress also decreases suffering, stress, and anxiety for the patient and family caregivers C aregivers Involve early Valuable information source Legally authorized surrogate Who called for help? Why? D ecision-Making Capacity Can the patient: Receive information? Process and understand the information? Deliberate? Make, articulate, and defend a choice? Decision-making capacity can exist in the setting of unstable vitals

30. Subacute Assessment – NEST Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html What should the Therapeutic goals be for this or hospitalization? T N Are there social Needs that can guide post-ED disposition and prevent repeat visits? Does the patient have Existential needs that mandate attention from ED providers? E S Which Symptoms , physical or psychological, require treatment during this visit?

31. Subacute Assessment – NEST (cont.) Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html Social Needs Access to care Caregiving Closeness vs. personal isolation Financial issues Consider engaging social worker colleagues Symptoms Physical symptoms Mental symptoms Harder to identify Therapeutic Goals of care Health information Therapeutic relationship Treatment plan Existential Needs Distress Worry/anxiety Dying words occur in any setting Allow expression of wishes, desires, hopes FICA Faith or beliefs Importance Community Address

32. Addressing Code Status As patient enters the advanced illness phase of a disease, it becomes important to address code status and advanced life support With effective, ongoing GOC communication, a provider can address these treatments in a timely manner and prevent unintentional harm to patient “Has anyone spoken to you in regard to your wishes about things like CPR and life support?” “What is your understanding of these interventions?” “We want to expect the best but prepare for the worst as well.” When appropriate, make recommendations: “At this point in your illness we only want to do things that will make sense. Things like CPR and intubation will likely only cause you harm, and if you did come out of it, you likely would not be as functional as you are now. I would recommend putting some limits there…”

33. Fitting Rapid Assessment Into Busy Workflows Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html Allow for interdisciplinary involvement in the assessment Delegate appropriate domains to save time Recommend an optimal care plan Coordinate interdisciplinary care Requires a team approach Must hear and respect evaluations and assessment of each member Neither realistic nor necessary for any single provider to assess and address all domains of suffering

34. Interdisciplinary Team Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html Prehospital care Triage/bedside nurse Physician/nurse practitioner/physician assistant Ancillary ED/hospital providers Chaplains Social worker Case manager/coordinator

35. Challenges Emergency Medicine. (2021). Emergency Medicine: EPEC: Education in Palliative and End-of-Life Care: Feinberg School of Medicine: Northwestern University. Retrieved from: https://www.bioethics.northwestern.edu/programs/epec/curricula/emergency-medicine.html Time Provider discomfort Belief that this is outside area of expertise Limited training throughout medical education Fear of patient/family reaction Reimbursement not in line for time required

36. Communicating Serious Illness A number of clinical tools exist to deliver bad news and facilitate GOC conversations SPIKES method (for stabilized patients) is in-depth and organized. However, it can require significant time from the clinician Difficult to implement in ED There are some important takeaways from the protocol 5-minute GOC conversation in the ED (for all patients) Fine-tuned to the fast-paced ED environment Helps to rapidly assess patient’s GOC and disposition to hospice and palliative care

37. The SPIKES Protocol Baile, W., et al. (2000). SPIKES—A Six‐Step Protocol for Delivering Bad News: Application to the Patient with Cancer. The Oncologist, 5(4), 302–311. SPIKES is an organized approach to delivering bad news and discussing GOC:

38. 5-Minute GOC Conversation Elicit patient’s understanding of underlying illness and today’s acute change If available, build on previous advance directives or documented conversations Acquire a sense of the patient’s values and character, to help frame prognosis and priorities for intervention Name and validate the patient’s observed goals, hopes, fears, and expectations Minutes 1–4 Discuss treatment options, using reflected language Continually re-center on patient’s (not family’s) wishes and values Recommend a course of action, avoiding impartiality when the prognosis is dire Minutes 3–4 Introduce ancillary ED resources (e.g., hospice, observation, social work, chaplain) Summarize and discuss next steps Minutes 5

39. Facilitating the GOC Conversation: SPIKES Protocol It is often necessary to use components of the SPIKES and 5-Minute Clinical Consult to effectively meet the needs of patients and families Do not forget to utilize other team members when facilitating GOC discussions Bedside nurse Care coordinator/case manager Social worker Chaplain

40. Introducing Hospice Save the “hospice” word until the end of the conversation Focus on the services and benefits of hospice for patients and their families Focus on the team approach and value of hospice’s interdisciplinary team members Focus on the benefits of expert symptom management in the patient’s preferred setting Focus on the Medicare (Part A) Hospice Benefit, which pays up to 100% of costs related to each patient's hospice diagnosis, including medical care, equipment, medications, and supplies

41. Reinforce Facts About Hospice Introducing hospice to patients and families is a challenge There are many patient and provider misunderstandings about hospice services: Myth Hospice is a place. Fact Hospice is NOT a place. It is a range of resources focused on comfort and quality of life. Myth Hospice is solely for patients who are actively dying. Fact Hospice is NOT only for the actively dying. E ligible patients have a prognosis of 6 months or less if the disease runs its normal course; care can continue beyond 6 months if a person continues to meet eligibility requirements. Overcoming these barriers requires communication with care and empathy

42. How to Introduce the Benefit Hospice Family Discussion Guide. (2021). VITAS Healthcare. Retrieved from: https://www.vitas.com/hospice-and-palliative-care-basics/when-is-it-time-for-hospice/hospice-family-discussion-guide Informational materials to help families understand the benefits of hospice: www.vitas.com / FindingHelpWithHospice “What if I told you there was a benefit available to your loved one at this point of his/her illness that covered the medications related to his/her illness, any medical equipment (s)he may need, nursing, aide, and physician services, and all this is provided in the home. Would you be interested in hearing more about these services?”

43. Hospice Care Interdisciplinary team-oriented approach to EOL care Patient- and family-centered care Goals of care/shared decision-making Aggressive care near the end of life: medical care, pain and symptom management, and emotional and spiritual support Provided in any setting 4 different levels of care, based on each patient’s clinical needs

44. Medicare Hospice Benefit These services and levels of care are mandated by the Medicare Hospice Benefit. Medication Interdisciplinary Team of Hospice Professionals Home Medical Equipment Bereavement Support Continuous Care Respite Care Routine Home Care Inpatient Care

45. Continuous Care Higher level of care Acute symptom management Patient’ s bedside/preferred care setting VITA S RN/LPN/LVN/aid e Temporary shifts of 8-24 hours unti l symptoms stabilize Prevents ED visits/hospital readmissions Respite Care** Provides temporary break (caregiver burnout, travel, work, etc.) Up to 5 days and nights of 24-hour patient care Medicare-certified hospital, hospice facility, or long-term care facility Routine Care Most common level of hospice care More robust and comprehensive compared to home health care services Patient’s preferred setting Proactive clinical approach helps prevent ED visits/hospital readmissions Four Levels of Care *Per Medicare guidelines, these 2 levels of care are provided on a temporary basis until the symptom(s) is optimally managed.**Usually not offered more than monthly General Inpatient (GIP) Care* Higher level of care (GIP/VITAS IPU) Acute symptoms can no longer be managed in patient’s preferred setting VITA S RN/MD/psychosocia l team Temporary until symptoms stabilize Prevents ED visits/hospital readmissions

46. Hospice Interdisciplinary Team

47. Patient Identification Does the patient have advanced illness or multimorbidity (e.g., advanced COPD, metastatic cancer, CHF, dementia, frailty)? Does the patient spend ≥ 50% of daytime hours sitting or resting (PPS ≤ 50)? Has the patient visited the ED or hospital 2+ times in the last 6 months? Do you think this patient could die within the next 6-12 months or during this visit? Has the patient experienced ≥ 10% weight loss in last 6 months? Recurrent falls with injury? Ongoing symptoms related to their terminal illness? Hospice Eligibility Identification Questions

48. General Hospice Guidelines: Significant Predictors of Poor Prognosis Dependent in 2-3 of 6 ADLs Confined to bed or chair > 50% of waking hours SOB or fatigue at rest/minimal exertion Multiple ED visits or hospitalizations 10% weight loss in 6 months Recurrent falls with injury Decreased tolerance to physical activity General Guidelines NYHA Class III/IV: Fatigue Angina Palpitations Dyspnea at rest and/or with minimal exertion ED visits, hospitalizations within last 6 months Not a surgical candidate Advanced Cardiac Disease

49. General Hospice Guidelines: Significant Predictors of Poor Prognosis (cont.) Advanced Lung Disease 3/6 ADL dependency Clinical complication: Pneumonia UTI Sepsis Weight loss 10% Two stage 3-4 pressure ulcers Hip fracture Swallowing difficulty Feeding tube decision Delirium Alzheimer’s/Dementia Disabling dyspnea – SOB at rest and/or with minimal exertion Oxygen-dependent plus Disease progression with either: ED visits or hospitalizations in past 6 months Cor pulmonale

50. Impact Kheirbek, R., et al. (2015). Discharge Hospice Referral and Lower 30-Day All-Cause Readmission in Medicare Beneficiaries Hospitalized for Heart Failure. Circulation: Heart Failure , 8(4), 733–740. https://doi.org/10.1161/circheartfailure.115.002153 Sanoff, H., et al. (2017). Hospice Utilization and Its Effect on Acute Care Needs at the End of Life in Medicare Beneficiaries With Hepatocellular Carcinoma. Journal of Oncology Practice , 13(3), e197–e206. https://doi.org/10.1200/jop.2016.017814 Literature now showing that hospice utilization: Lowers rate of hospitalization and ED visits Lowers rate of ICU utilization Lowers rate of in-hospital death Similar evidence has been demonstrated with chronic illnesses: Hospitalization 88% less likely for heart failure patients enrolled in hospice care

51. How VITAS Can Help VITAS Palliative Care Home Health Eligibility Requirements Prognosis required: ≤ 6 months if the illness runs its usual course Prognosis varies by program, usually life-defining illness Prognosis not required Skilled need not required Skilled need not required Skilled need required Plan of Care Quality of life and defined goals Quality of life and defined goals Restorative care Length of Care Based on plan of care Variable Limited, with requirements Homebound Not required Not required Required, with exceptions Targeted Disease-Specific Program ✓ Variable Variable Medications Included ✓ X X Equipment Included ✓ X X After-Hours Staff Availability ✓ X X RT/PT/OT/ S peech ✓ X ✓ Nurse Visit Frequency Based on plan of care Variable Limited, based on diagnosis Palliative Care Physician Support ✓ Variable X Levels of Care 4 1 1 Bereavement Support ✓ X X

52. Other Approaches Add references and link Reframe R Expect emotion E Map the future M Align with patient values A Plan treatment P

53. Other Approaches Add references and link Choose the approach that best fits your practice’s needs Setup S Understanding U Priorities P Explain E Review and Recommend R

54. Additional Hospice Resources The VITAS mobile app includes helpful tools and information: Interactive Palliative Performance Scale (PPS) Body-Mass Index (BMI) calculator Opioid converter Disease-specific hospice eligibility guidelines Hospice care discussion guides We look forward to having you attend some of our future webinars! Scan now to download the VITAS app.

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