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
- Personnel:
- Hospice can be offered to patients without insurance
- Eligibility: less than or equal to 6- month life expectancy
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