Hospice of Kitsap County's Guide for Physicians

Transcription

1 Hospice of Kitsap County's Guide for Physicians Includes Medical Guidelines for Determining Prognosis Dear Doctor: Hospice of Kitsap County is providing you with these guidelines as part of Hospice s Physician Information Service to serve as a reference and assist you in the care of your patients. Our Interdisciplinary Team is available for consultation and assistance in providing the best home hospice care for your patients. We are a Medicare and Medicaid certified, state-licensed agency with more than 20 years of home hospice care experience. We are a member agency of the National Hospice and Palliative Care Organization, Washington State Hospice Organization, United Way of Kitsap County, and the Bainbridge Island Foundation and have a reputation for excellence and high professional standards. We thank you for trusting Hospice of Kitsap County to work with you in caring for your hospice-appropriate patients. Kate Brostoff, M.D. Medical Director of Hospice James E. Pledger Executive Director of Hospice PROGRAM SERVICES Hospice care emphasizes the importance of the family-patient-doctor relationship and is a way of insuring that individuals in the final stages of a life-limiting illness receive the full range of palliative medical, nursing and supportive services. Hospice Services Include: Care 24 hours per day, 7 days per week Care for adult and pediatric patients with cancer or non-cancer diagnoses Pain control and symptom management, including medications related to the Hospice diagnosis Professional nursing and home health aide care Social work, spiritual, and bereavement counseling Trained volunteers for respite and bereavement support Grief and loss support programs When Part of the Individual Hospice Plan of Care: Short-term inpatient respite care at contracted facilities Short-term inpatient care for symptom management at contracted hospitals and facilities Dietary consultation, rehabilitative therapies (physical, occupational, speech), medical supplies and durable medical equipment

2 CRITERIA FOR ADMISSION The patient has a terminal illness with an approximate life-expectancy of six (6) months or less.** The physician has informed the patient (and family, with patient s permission) of the diagnosis and prognosis.* The patient, family, and the physician agree to palliative (non-curative) care in the hospice program.* A willing primary caregiver is available, or, with the assistance of the Hospice team, the patient is able to develop an alternative plan for caregiving when no longer able to care for self. * It is not necessary that the patient or the family accept the diagnosis or prognosis, nor is it necessary that the patient acknowledge that his/her illness is terminal. It is, however necessary that the patient be fully informed about the palliative nature of care, the diagnosis and prognosis. ** If the disease follows its usual course. Preparing Patients for Hospice (From the National Hospice & Palliative Care Organization) We are going to treat you aggressively, but a time may come when we will have to change our focus from cure to comfort. My commitment to you is that I will be honest about what I am seeing. (B. Baines, M.D. Family Practice) We must be honest and say, I don t have any more treatment that will cure your disease. Then we must be good physicians and add, I do have treatment that will ensure your comfort. I will be here for you. (E. Anderson, M.D. Internal Medicine) For many people, fear of the unknown is at least as great as fear of death itself. Presenting hospice as a medical option for treating a terminal illness can help with many unknowns fear of uncontrollable pain, nausea, vomiting, embarrassment and especially abandonment that often accompany end-stage disease. (Fletcher and Creagan) Your Patients Will Be Reassured If You Can Say: As your physician, I will continue to see you and care for you Our first priority is managing your symptoms Services are available where you live Your family / caregivers will also receive the support of the hospice team HOW ARE HOSPICE SERVICES FUNDED? / PHYSICIAN REIMBURSEMENT ISSUES Physician Reimbursement: Services of the patient s attending physician are billable directly to Medicare/DSHS/Private Insurers, just as though the patient were not on Hospice care. Physicians attending Medicare hospice patients may also bill for care plan oversight: G0065, for oversight services in excess of 30 minutes per month. Consultative services related to the hospice diagnosis must be approved in advance by the Hospice Team. Private Insurance: Each person s insurance policy differs. Hospice of Kitsap County will verify which benefits insurance covers. Most insurance policies, including HMO s and PPO s, include hospice benefits. Medicare and DSHS (Medicaid): Congress has passed legislation creating a Hospice benefit under Medicare. Also, Washington State has implemented a hospice benefit under DSHS. Participation in these certified hospice programs is voluntary. To elect this kind of care, the patient must: 1 Be eligible for Medicare (Part A) hospital insurance or be currently eligible for Medicaid. 2 Have his or her physician and the Hospice Medical Director certify that he/she has a terminal illness. 3 Sign appropriate consent forms electing to receive hospice care in place of the standard Medicare/Medicaid benefits. Self Pay: The patient or family may pay directly. Financial consideration is available.

3 GUIDELINES FOR PALLIATIVE CARE The decision to maintain the patient in a palliative mode of care (symptom management and pain control) is a joint decision to be made by the patient, family, and physician. Palliative Care Active Interventions: Physical discomfort must be relieved before addressing all other forms of suffering: emotional, social, and spiritual. At the time of the first visit to the home, the hospice nurse will perform an initial assessment for pain and/or level of comfort. A review of systems for symptom management is conducted with special emphasis on: 1 Gastro-intestinal symptoms 2 Bowel and bladder function 3 Skin care 4 Nutrition/hydration needs 5 Safety of home care situation 6 Caregiver education needs 7 Other patient/support system needs In addition, needs for psychosocial and spiritual support are evaluated, and services are offered to help the patient and the family cope with and accept the process of dying. PAIN MANAGEMENT General Process for Pain Management: Assess for multiple causes pain (physical, related or unrelated to primary diagnosis) Treat each type of pain (use adjuvants for bone, neuropathic, visceral pain) Reassess continuously, especially when pain remains uncontrolled Pain Management Pearls: Dose pain medications by the patient : pain is subjective/use rating scale/ believe the patient by the clock : around the clock, not prn by the mouth : oral is the best route when possible All new orders for strong opioids should be accompanied by: Order for a stimulant laxative (e.g. senna) Strongly consider an order for at least a few doses of an anti-emetic An order for breakthrough pain medication if a longacting agent is ordered Equianalgesic conversion table: (abbreviated version) Oral/Rectal Dose (mg) Analgesic Parenteral Dose (mg) 100 Codeine 15 4 Hydrocodone (VICODIN) Hydromorphone (DILAUDID) Morphine 5 10 Oxycodone (PERCOCET/ TYLOX) (Transdermal Fentanyl Patch (DURAGESIC) 100 mcg strength approximately = Morphine sulfate 30 mg po q 4 hours = Morphine sulfate 180 mg/24 hours) Commonly Prescribed Pain Medications Pain rated on a scale of 0 to 10 Common starting doses include: Acetaminophen mg po/pr q 6 hours Ibuprophen mg po q 6 hours Hydrocodone/APAP 5/500 mg 1-2 tabs po q 4-6 hours Sustained release morphine tabs: mg po/pr q 12 hrs (MS CONTIN) or mg po/pr q 8 hrs (ORAMORPH) For morphine intolerant patients: OXYCONTIN mg po q 12 hrs or Hydromorphone (DILAUDID) 4 mg po q 4 hrs For breakthrough pain: Oxycodone 5-10 mg po q 4 hrs prn Morphine mg 1 tab SL/po q 15 min prn Liq. Morphine 20 mg/cc 1/4-1 cc po/buccal q 1-2 hrs prn Hospice Medications Often Used In Terminal Care: Lorazepam (for agitation/anxiety/dyspnea): 0.5 mg tabs (#15) Prochlorperazine (for nausea/vomiting): 25 mg suppositories (#6) Morphine (for pain/dyspnea) : 10 mg SL tabs (#15) Acetaminophen suppositories (for fever): 650 mg (#12) Hyoscyamine (Levsin) gtts. (for secretions): One bottle Haldol (for terminal delirium): 1 mg tabs (#10)

4 GUIDELINES FOR PALLIATIVE CARE OF COMMON SYMPTOMS BY SYSTEMS Physicians are welcome to request copies of our pre-printed order sheets. Gastrointestinal: CNS Respiratory Bowel Program (step wise regimen) a Docusate 100mg po 1 cap BID b Senna (Senokot) or Bisacodyl (Dulcolax) po 1 q day c Senna or Bisacodyl 1 tab BID d Senna or Bisacodyl 2 tab BID e Senna or Bisacodyl 3 tab BID f Senna 4 tabs BID plus Lactulose 15 ml q day g Senna 4 tabs BID plus Lactulose 15 ml BID h Senna 4 tabs BID plus Lactulose 30 ml BID i Fruit paste and / or Senna Tea Diarrhea Clear liquids, plus one of the following: Kaolin mixture per bottle directions Loperamide tab po after each loose stool up to 8 doses qd Diphenoxylate hydrochloride 5 mg po after each stool up to 8 doses per day Nausea/Vomiting NPO until vomiting subsides Prochlorperazine 10 mg po or 25 mg suppository pr q 6 h prn Promethazine 25 mg po or 25 mg suppository pr q 4-6h prn Reglan 10 mg po ac and HS Sleep Pattern Disturbance and Anxiety Diphenhydramine 25 mg q HS prn Lorazepam 1 mg - 1 tab po/sl q 6 hr prn Zolpidem (Ambien) 10 mg 1/2-1 tab po q HS prn Zaleplon (Sonata) 5-10 mg po qhs prn Secretion Management Atropine 0.5 mg IM/SQ/po q 4-6 hours prn Hyoscyamine (Levsin) gtts, po/sl 1-2 gtts. prn Oxybutynin (Ditropan) 5-10 mg po q 8 hrs prn Mouthcare of Choice Artificial Saliva Viscous Lidocaine as directed Candidiasis (oral/perineal) Nystatin suspension swish/swallow QID X 7 days Clotrimazole troches 5 times a day x 7 days Fluconazole 100 mg po 2 tabs first day; then 1 tab qd for 4 days Miconazole/clotrimazole vaginal cream; one applicator at bedtime x 7 days Antifungal cream topically prn. Dyspnea Bedside fan Oxygen at 1-3 1/m per nasal cannula prn Lorazepam 1 mg tabs - 1 tab po q 6 hours prn Morphine 2-10 mg po/sl q 4 hours prn Skin Pruritis Hydroxyzine 25 mg, 1 po q 8h prn Diphenhydramine mg po q 6h prn Hydrocortisone 1% cream topical 2-4 times a day prn Pressure Areas / Skin Care Hydrocolloid dressing prn (e.g. Duoderm) Occlusive opaque dressing prn (e.g. Tegaderm) Alternating pressure mattress prn Barrier protection ointment

5 BENEFITS TO PHYSICIAN Because the care needs of a dying patient encompass more than medical treatment of a disease, the hospice team can be a valuable resource in dealing with complex end-of-life issues and extending the physician s care. A Hospice referral can result in better care coordination, less panic, and more feelings that things have gone well and that the patient was well served. Service: Hospice Care Medical Director Supervision Patient Education Patient and Family Services Description: Comprehensive case management. Skilled nursing. Pain control. Titration of medication under physician supervision. Assistance in locating other necessary resources. Coordinating and securing supplies/equipment. Full support to patient s home. Certifies all admissions as appropriate for hospice care. Reviews all hospice treatment plans. Provides education and direction to hospice team. Available for consultation (no cost) with attending physician on treatment plans and other issues. Hospice nurse, in coordination with attending physicians, educates patients and their families in: comfort measures, signs of distress and how to respond, anticipating and coping with crisis episodes, the disease process, and when to call the doctor. Hospice care reduces stress and increases coping abilities of patients and their families. Hospice helps patients and their loved ones make the most of their time together. Hospice helps families prepare for the dying process. Social worker assists patients and their family members with locating available community services ( e.g. financial services, Meals-On Wheels, etc.). Establishes relationships with local agencies to provide patients and their families with low cost assistance, if needed. Spiritual caregivers provide multi-denominational spiritual support, if desired. Volunteer program for companionship, running errands, light house work and short periods of respite care. Bereavement programs for families including adult grief and loss support groups and specialized programs for children and adolescents. Physician Benefit: Medical management at patient s home. 24 hour availability of skilled care. Extension of physician through hospice team. Physician control of patient s program. Physician convenience. Assurance of continuity with attending physician s treatment plan. Completes quality assurance cycle. Helps physician maintain patient s highest levels of comfort and functional abilities. Maximizes effectiveness of time with physician. Hospice team is able to coordinate many activities and answer many questions previously added to the workload of the physician and the physician s staff. Hospice of Kitsap County 3100 Bucklin Hill Road, #101 Post Office Box 3416 Silverdale, WA phone: (360) fax: (360) To make a referral to Hospice, please call the Companions in Care Referral Center at (360)