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Hospice

Background

  • Hospice: aims to provide aggressive palliative care for patients at the end of their life, usually when life-prolonging treatment options have stopped
    • Eligibility: less than or equal to 6- month life expectancy
      • Consider: palliative performance scale (PPS) rating of \<50-60%, dependence in 3 of 6 ADL’s, alteration in nutritional status, or documented deterioration in 4-6 months
    • Levels of Care
      • General inpatient care: Patients must require skilled nursing care that could not be provided at home (IV medications, suction, high flow O2,) No cost to the patient under this level of care.
      • Home hospice-Patients are discharged to their "home”: which could be a long term care facility, assisted living facility, or their house.
    • What is covered?
      • Personnel:
        • Hospice RN visits at least weekly and as needed; crisis on-call visits available 24/7
        • SW, Chaplain, Hospice MD oversight
        • CNAs: usually 1 hr, 2-3/wk at most
      • Medicines for comfort
      • Medical equipment for comfort and safety including oxygen
      • Up to 13 months of bereavement for caregivers after the death
      • Respite care for 5 days, usually in a nursing home
      • Inpatient hospice at hospice facility or at certain hospitals for symptom control for up to 7 days
    • Hospice can be offered to patients without insurance

VA Specifics for Hospice

  • Main difference compared to VUMC is pt is allowed concurrent care
    • This means vets can continue to receive some treatments for the primary condition (e.g., palliative radiation or chemotherapy) and still receive hospice services
  • Additionally, all veterans that go on hospice should have any needed nursing home stay (at a contracted SNF) covered by the VA regardless of service connection
  • VA Palliative Care team will help with these referrals
  • One (1) F Status at the VA
    • Designates “treating specialty” as NA-HOSPICE. Reduces costs for families, helps quality metrics. Use this if patient qualifies and agrees to hospice care
    • Write Delayed Transfer Orders: Admit to NA-HOSPICE and Specialty as “Hospice for Acute Care”
    • Write a nursing text order to “Change Patient to 1-F Status”

Medications for Imminently Dying Patients

General recommendations

  • At VUMC, there is a very helpful order set titled “Comfort Care Orders (Trauma, MICU, SICU, NEURO ICU, Palliative Care”
  • Make sure to remove unnecessary medications, labs, telemetry, nursing text orders, etc.

Pain

  • Morphine 2mg IV or SQ q1h PRN (avoid if renal failure)
  • Hydromorphone 0.25 – 0.5mg IV or SQ q1h PRN
  • Write as PRN, as needed for pain > 2/10 or for air hunger
  • If ineffective after 1 hours, increase by 50-100%
  • If given every hour for 3-4 hours, consider an infusion (given PRN dose as hourly rate)
  • Fentanyl is not a great option in ICU unless it is a continuous drip. Bolus lasts only 15 mins

Dyspnea/Tachypnea

  • Assess for volume overload, considering decrease or stopping IVFs or tube feeds
  • Opioids are the treatment of choice for dyspnea
  • Consider Benzodiazepines for air hunger not controlled by opiates
  • Supplemental oxygen for comfort (do not base on O2 sat). Consider use of cool air or fan

Restlessness/agitation/anxiety

  • Assess for urinary retention, constipation, pain, other modifiable factors
  • Lorazepam (Ativan) 0.5 – 1 mg PO or IV q4h PRN (tablet can be made into slurry if patient is experiencing dysphagia)

Nausea

  • Ondansetron (Zofran) 4mg IV q4h or 8mg q8h PRN
  • Promethazine (Phenergan) 25mg PO or PR q6h PRN; caution can be very sedating
  • Prochlorperazine (Compazine) 10mg PO or IV q4h PRN
  • Haloperidol (Haldol)
  • If felt to be obstructive in etiology, try Dexamethasone 4mg IV or SQ q8-12h with Octreotide 100-400mcg IV or SQ q8h
  • If felt to be related to anxiety, try Lorazepam; see dosing above
  • Scopolamine is highly anti-cholinergic and takes time to be effective, so would NOT use in imminently dying patients

Secretions

  • Remember: the patient is NOT bothered by their own secretions, and it is often the family and caregivers who are likely disturbed, so avoid deep suctioning
  • Glycopyrrolate (Robinul) 0.2 – 0.4 mg SQ or IV q6h PRN
  • Atropine 1% Ophthalmic Solution 2 drops sublingual 2-4h PRN
Last update: 2022-07-05 14:21:37