South Florida Hospital News
Tuesday August 4, 2020
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February 2005 - Volume 1 - Issue 7
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Hospice Care for End-Stage Cardiac and Pulmonary Patients

After many years of neglect, American society and American medicine have been re-examining how we approach death and dying, as well as how we care for people at the end of their lives.

With the Baby Boomer cohort beginning to approach retirement age, the reality is that the American population is getting older. Despite our many technological advances, people still will die as a result of cancer, heart failure, stroke, respiratory failure and many other chronic terminal conditions characteristic of our Western culture.

A groundswell of interest in end-of-life care has been notable perhaps since the mid-1990s, both in our professional societies as well as through advocacy organizations (AARP, among many others). The American College of Cardiology, the American College of Chest Physicians and the American Geriatrics Society have been in the forefront of educating and implementing changes to shape the attitudes and practices of physicians, policymakers as well as the health care system itself.

As a model of healthcare, hospice has come of age and now is "mainstream" in our training and professional lives as caregivers. Hospice aims to fill the void where for many years we failed to relieve suffering beyond curative care while improving quality of life at its end.

A major influence in the United States in this regard was implementation of the Medicare Hospice Benefit in November 1983. More than 20 years later, however, most physicians, hospital administrators and long-term care executives still do not fully realize that patients can access these broad benefits, which are reimbursable through Medicare Part A, Medicaid in most states, including Florida, and managed care.

The worthiness of hospice has been validated: it is considered the gold standard of end-of-life care because it is usually high quality and cost effective. Another benefit includes: structured resources and assets to efficiently deliver customized care. It meets JACHO standards and decreases costs while increasing capacity. It facilitates discharge planning and helps the time-intensive patient/family communication process.

In terms of cost, it has been shown that hospice has saved 10 percent of Medicare dollars in the last year of life and up to 17 percent in the last six months and 25–40 percent in the final month of a patient’s life.

A significant aspect of current hospice guidelines, includes a timely discussion with a hospice-appropriate patient regarding her/his options of care and advance directives and a living will. A patient with chronic, refractory heart failure who has been optimally or maximally treated, or a COPD patient who has failed treatment and rehabilitation and now lives a bed-to-chair existence with frequent EMS and ER visits are both appropriate candidates for a hospice referral.

When care in an ICU is beyond curative value and even possibly futile, hospice offers an opportunity to provide care "when there is nothing else to offer." In these instances, the objectives are to relieve suffering, and to treat the obvious symptoms of breathlessness and pain. At the same time, we can confidently and professionally manage these symptoms with a combination of, but not limited to, anxiolytics and analgesics.

In addition, our focus now becomes the patient/family unit; all necessary support is addressed, including their faith or belief systems. The care could be initiated in an Intensive Care Unit, a hospital setting or, if appropriate, continue at home—wherever home is (private residence, nursing home or assisted living facility).

One of the main barriers to effective participation in the hospice benefit is late referrals. If physicians, social workers and administrators were to refer patients for hospice services earlier, then patient and families would benefit more fully from the array of medical and psychosocial services provided by the hospice interdisciplinary team.

Hospice and palliative medicine is an integral part of our healthcare system and has earned a respected reputation as a trusted, vital partner and visible advocate for our aging population that needs it.

Freddie J. Negron, M.D., F.C.C.P., Medical Director, VITAS Innovative Hospice Care® of Miami-Dade, can be reached at (954) 437-2057 or freddie.negron@vitas.com.
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