Palliative care is available for people who need more advance control of their symptoms and is intended to improve the quality of life by relieving pain, reducing or controlling symptoms and addressing the physical, emotional, social and spiritual needs of the patient. Palliative care consults can be requested at any time, regardless if the patient is in the hospital or not. Palliative care can be found in hospitals, skilled nursing facilities, clinics, rehabilitation units, and assisted care facilities. The palliative care team consists of a Physician, Nurse, Chaplain, Psychologist, and a Social Worker and others. Palliative care works in parallel to conventional treatment.
A system of patient-centered care designed to assist the terminally ill person be more comfortable and help maintain dignity and quality of life through the final phase of life. Hospice care is multidisciplinary and includes home visits, on-call professional care, teaching, emotional support for the family, and physical care of the client. Some hospice programs provide care in a designated care facility such as a skilled nursing facility. Hospice can also be provided at home. Bereavement counseling for the family is available for up to six months after their loved one has passed.
Hospice originated in England and emerged in the United States in the 1970s. The philosophy of hospice is simple, terminally ill patients should live their last few months as comfortable as possible preserving function, proper mental status, dignity and respect. Hospice is mostly comfort rather than curative, however, in some cases chemo therapy and radiation treatments can be administered if it is for palliative means only. It is important to note that Hospice does not hasten death nor does it postpone it.
Medicare does cover hospice services both in hospital (excluding room and board), and home. The cost of room and board aspect of hospice is the responsibility of the individual or family and/or supplement insurance such as Medicaid. Some commercial insurance cover hospice but it may differ slightly from the standard Medicare coverage. Hospice agencies provide skilled nursing services as an on-call service, meaning that Medicare and other insurances do not pay for continuous nursing care. During hospice, a nurse reassesses the patient frequently for changes in condition and updates the care plan as needed in consultation with the hospice physician. Non-skilled services are also not covered by Medicare, Medicaid or most commercial insurances. These services may be provided at the discretion of the individual hospice agency in limited amounts usually only for 24 to 48 hours to give the family time to adjust and make further arrangements. Hospice patients are under the continuous care of a hospice/ palliative care physician and provide medical services which are considered palliative and not curative. Other services that are provided by hospice include: social services, case management, spiritual care, volunteers, bereavement services and counseling.
Medications that are directly involved in the management of symptoms are covered by Medicare with a small administrative charge. Durable medical equipment such as, hospital beds, IV pumps, oxygen are covered by Medicare and commercial insurance. Respite care is designed to give a much-needed break of duties to the family members providing most of the care to the patient. During this time the patient will be cared for by the hospice staff or brought to a skilled nursing facility and cared for by the facility staff for up to one week.
Eligibility for hospice care includes a terminal illness with a life expectancy of no more than six months and this applies to all ages. An individual may go through a dis enrollment from hospice at any time for any reason. Referrals to hospice can come from many sources such as, case management, social work, discharge planner, palliative care physician, the individual or family. The hospital staff including case managers and social workers can suggest and recommend local hospice agencies. Many hospitals have forged relationships with hospice providers in the community and the patient has the right to choose any hospice agency. As with anything, not all hospice agencies are created equal and it is a good idea to seek out a good referral.
As of 2015 Medicare has begun a pilot program which allows certain individuals to be on Hospice services and curative care at the same time. Okay, so what does this mean? Normally patients must give up treatment that is designed to help cure one of an ailment to be enrolled onto hospice care. With this pilot program, Medicare Care Choices Model (MCCM), patients can stay with the current curative treatments like chemotherapy and get the benefits of Hospice care. However, patients do need to meet the strict criteria set forth by Medicare. More information can be obtained from the (CMS.gov) website. Type” MCCM” in the search box on the site.
General Inpatient Care
There are times where the symptom management of the patient on hospice is very complex and aggressive management is needed which can only be done in an inpatient type setting. In these cases, a patient can be admitted to what is called General Inpatient Care at either a hospital or skilled nursing facility for a short time while the issue is being taken care of. Once reasonable management of the issue is resolved the patient can be transferred to either the home setting or to another facility. Medicare and private commercial insurance normally pay for the hospice care itself but not the board and care of a facility. This is normally paid by supplemental insurance or Medicaid. This is another benefit that you should ask your health plan about to see if it is covered.
Advanced Health Care Directive
If you cannot express your wishes due to being medically incapacitated, the advanced health care directive (AHCD) acts as your voice. It is a written statement of your wishes, preferences and choices regarding care. It also identifies who can act as your representative or agent. The AHCD can be initiated by anyone who is over 18 years of age. The AHCD contains the following information: the name of the appointed agent, instructions for future treatment, documents the wishes of the patient, choice of physicians, medications for pain control, organ donation, disposition of remains and autopsy. Appointing an agent is an important aspect of the AHCD. You may appoint anyone who is not: your health care provider or an operator of a community health care facility where you receive care. You are not required to appoint an agent, it is highly recommended to have someone whom you trust to make medical decisions on your behalf. It is wise to have an open discussion with your appointed agent so that he or she has a good understanding of your health care wishes. This agent’s decision will override any wishes of friends and next of kin. Once the AHCD has been properly filled out it must be witnessed by a notary or two witnesses who are not related to you or each other. Once the AHCD is filled out and properly signed it should be distributed to: your physician, agent, family, clergy, health plan or medical group and the state registry. The AHCD goes into effect once you become unable to express your wishes by any means. You can make changes to this document whenever you like and there is no limit to how many times. Each time changes are made you are required to have it signed by a notary or two witnesses.
The physician order for life-sustaining treatment is a document which expresses your desire to receive lifesaving treatment or not. Normally, this document is reserved for seniors and terminally ill patients. However, any person over the age of 18 years can have a POLST completed. Depending on the state, the POLST is a brightly colored document. For example, in California the POLST is a bright pink heavy card stock document. The document contains four sections A thru D.
This section concerns itself with cardiopulmonary resuscitation (CPR). There are two choices in this section. Attempt CPR or do not attempt CPR.
This section concerns itself with medical interventions the three choices are:
1. Full treatment: this is where the primary goal is to prolong life by all medically effective means.
2. Selected treatment: the goal is to treat medical conditions while avoiding burdensome measures.
3. Comfort focused treatment: the primary goal is to maximize comfort.
*Additional orders may be handwritten by the physician.
Artificially Administered Nutrition.
1. Long-term artificial nutrition that includes feeding tubes
2. Trial of artificial nutrition that includes feeding tubes
3. No artificial means of nutrition
This section contains additional information and signatures
*Both the patient and physician sign in this section
It is a good idea to have this form displayed in a conspicuous area; this helps direct EMS personnel if you should suffer a life-threatening incident. For more information regarding this form can be found on your states government website.
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