Hospice Care Initiation


This module addresses best practice techniques for initiating care, implementing comfort and safety measures.  Click these links to navigate through sections of the Hospice Care Initiation module:

Critical Interventions at the First Visit
Hospice Crisis Management
Hospice Medication Management

We also recommend users review Blueprint for Excellence modules applicable to all patients, and the Initiate Safe Care module for information on falls prevention and other safety measures.
 
Critical Interventions at the First Visit

ElevatingHome Best Practice
  1. Use the same clinicians for the first and second visit to ensure continuity of care.
  2. If patient cannot tolerate a long first visit, part of the physical assessment by the RN and psychosocial assessment by the MSW can be completed on the following day.
  3. Use the teach-back method on the second visit to assess what the patient/caregiver learned from the first and to improve information retention.
  4. Identify high-risk patients prior to full admission when possible.
  5. Consider the use of some form of telehealth monitoring especially in hard-to-staff regions or in rural areas.
To develop a therapeutic relationship, training for staff should include strategies for establishing effective communications:
  • Listen more than talk
  • Encourage the patient and caregiver to articulate their concerns
  • Engage in “artful conversation”: use of silence, reflection, clarification, suspending judgment and use of presence
  • Use of motivational interviewing
  • Guide the discussion and enable patients and caregivers to speak openly.
Recommended elements of initial hospice care:

Clinical Assessment and Intervention:
  • All patients should be seen within 24 hours of institutional discharge or referral. In many cases, the RN and MSW should make a joint visit.
  • If patient/caregiver unable to tolerate a long initial visit plan for revisit the next day. Determine if RN or MSW should return, or both. Determine if there is immediate need for other members of the interdisciplinary team (IDT). Make sure patient is safe before leaving the home.
  • Ensure administrative forms including Consent for Treatment, the Notice of Election, a statement of Rights and Responsibilities and any other required paperwork are signed.
  • Provide a full discussion of hospice covered services, including levels of care, disciplines available, physician services, pharmacy and DME coverage as per the patient’s insurance benefit.
  • Determine the patient’s ability to answer questions; engage in therapeutic conversations with both patient and caregivers to complete the comprehensive assessment.
  • Assess the current care giving situation including the physical environment and availability of caregiver or paid caregivers. Identify any concerns expressed by the patient or caregivers regarding care giving and any apparent limitations of caregivers.
  • Assess the patient and caregiver knowledge/understanding of the disease process, treatment plan and prognosis. See Blueprint section on Treatment Preferences and Beliefs for a discussion of DNR, hospitalization and other treatment preferences interventions. Questions could include:
    • What do you call the problem you are having?
    • When and how did it start?
    • What do you think caused it?
    • What do you think will happen?
    • What do you fear most about the problem?
    • What have you done to feel better?
    • When a condition is life threatening or life limiting, should one “tell the truth” or “avoid the topic”?
  • Complete a full nursing assessment. This should include a History and Physical, with emphasis on assessment of all symptoms patient is experiencing, psychosocial, and emotional issues, coping mechanisms, and medication reconciliation and management.
  • Investigate the importance of cultural belief/values/practices of the patient’s culture of origin and determine if there are manners/customs requested by patient/caregiver (such as removing your shoes when you enter the house).
  • If the patient lives alone, initiate a discussion of what the patient would like to have happen when the patient becomes dependent and unable to meet his/her needs.
  • Determine if the patient is at high risk for re-hospitalization.
  • Utilize an emergency care plan that clearly explains how the patient/caregiver can contact hospice.
  • Implement documentation/assessment guidelines developed for non-cancer diagnoses such as Alzheimer’s disease and related disorders, cardiac, pulmonary, renal, liver, HIV, ALS, stroke, coma, and general terminal decline.
  • Complete a nutritional assessment including height and weight, BMI, mid arm circumference, any dietary restrictions, and current dietary intake.
  • Working with multiple members of the IDT, complete a functional assessment, including both ADL’s and IADL’s.
  • Determine what DME the patient is using or needs and whether or not it would be covered by the patient’s hospice benefit.
  • Make referrals to MSW, Home Health Aide, Chaplain, Volunteer and/or Bereavement services if patient/caregiver agree.
  • If needed, discuss status of funeral plans (this conversation can be timed according to hospice personnel’s assessment of imminence of death).
  • Initial visit information should be discussed at IDT meeting by all members who have visited the patient. The care plan should be reviewed and agreed upon by the IDT.
  • Initiation of care is not complete until all members of the IDT have done an assessment of the patient’s needs and developed interventions that are incorporated into the Plan of Care.
  • If initiation of care is for General Inpatient Care (GIP) documentation should include the following:
    • Reason for GIP stay
    • Is patient experiencing rapid deterioration?
    • Goals of GIP stay
    • Reason why care cannot be managed at home
    • Is the patient expected to return to routine home hospice care?
  • See Blueprint section on Crisis Management for additional Crisis Admission Interventions. 
Spiritual Assessment
Spiritual care assessment should include the following domains:
  • Religious affiliation if any
  • Place of worship and name and contact information of any clergy the patient/caregiver wishes hospice to contact
  • Invite clergy to IDT
  • Assessment of spiritual beliefs/strengths and resources for comfort.
  • Assessment of any areas of spiritual distress – areas of discomfort or struggle.
  • Any cultural issues/concerns impacting spiritual plan of care.
  • Provide interventions based on identified needs such as prayer, clarification of beliefs, expression of feelings, funeral preferences, life review, spiritual/emotional support, communication/coordination with community clergy.
Psychosocial Assessment
A complete psychosocial assessment should include the following domains:
  • Primary language and any interpreter services needed as well as patient’s ability to express thoughts, feelings and needs
  • Other individuals/caregivers participating in interview
  • Type of living arrangements and supportive care availability.
  • Caregiver and/or friends available for caregiving
  • Psychosocial history of illness and response to illness including emotions, comfort, dignity/respect.
  • Preferred environment of death for patient.
  • Preferred environment of death for caregiver.
  • Cognitive status
  • Community resources available/needed/accepted
  • Help with funeral arrangements if requested.
  • Financial need
  • Survivor risk assessment with referral to Bereavement for concerns.
  • Emotional/caregiver counseling needs identified.
Patient/Caregiver Training and Education
  • Develop and implement plan for preventing common symptoms and the plan for care in the final days/hours.
  • Coach on possible scenarios such as cardiac/respiratory failure, hemorrhage or other applicable symptoms
  • Educate on how to communicate with the hospice during and after hours, use of emergency services and other emergency responses.
Hospice Crisis Management
Quality of care for end of life patients in crisis is dependent on the hospice being able to anticipate the cause of the crisis and quickly respond to intervene in such a way that the crisis is resolved. Patients/caregivers who feel well supported at home are less likely to wind up with an unanticipated or unplanned admission to an acute care facility. This section addresses crisis management both for newly admitted patients (crisis admission) and patients who have been on the hospice program (currently enrolled hospice patient).
 
Why Crisis Management?
  • Hospice professionals frequently encounter patients and caregivers in crisis.
  • Symptoms of physical or psychosocial issues may emerge in the final days or hours.
  • Crisis level services such as Continuous Home Care or General In Patient Care are required by the Medicare Conditions of Participation.
  • Crisis admission and crisis care require a specialized skill set.
  • The initial assessment may be a crisis visit.
  • Patients who have been stable may enter a crisis due to uncontrolled symptoms.
ElevatingHome Best Practices
  1. The hospice program has a mechanism in place to identify the risk of a hospice admission being a crisis admission for the patient and/or caregiver.
  2. An intervention plan for the initial visit addresses those identified high risk issues.
  3. The hospice program has a plan in place to respond to patients already enrolled in hospice if a crisis develops.
  4. For a patient in crisis hospice personnel provide Continuous Care at home or if the crisis cannot be managed at home transfer the patient to General Inpatient care at a facility.
Critical Interventions

Crisis Admission
  • Staff should be trained to identify red flags that indicate a possible crisis admission.
  • Additional support or information may be needed by caregivers to help them make the hospice decision.
  • Assessment for the need for crisis intervention starts before admission through a phone call to the patient/caregiver and through obtaining information from the referral source. Ask if the patient is in acute pain or having other acute symptoms, has been discharged from the hospital, is a pediatric case, has caregivers in crisis.
  • Quick assessment of the patient is crucial during the initial visit.
  • Evaluate the patient/caregiver’s ability to learn and to administer medications.
  • Explore available support systems including available caregivers.
  • Begin to explore goals of care related to CPR and re-hospitalization and other treatment preferences and assure they are documented.
  • Involve both nursing and social work in the initial visit.
  • Evaluate the patient and caregiver’s understanding of the nature of hospice care. Do the patient and caregiver know that the patient is dying? Does the caregiver verbalize realistic expectations about hospice care?
  • Red flags indicating a crisis admission visit may include the following:
    • A new diagnosis
    • A very rapid decline in status
    • Desire for more curative therapy
    • Conflicted emotions about hospice services
    • Conflicted goals regarding CPR and place of death
    • Undiagnosed or unexplained clinical symptoms
    • Emotional or spiritual distress related to declining status
    • Patients who have been pursuing aggressive treatment in a hospital and are discharged quickly to hospice.
    • Unclear advanced directives
    • A new physician provider (e.g. transition from oncology, PCP to hospice physician.
  • For crisis admissions, consider a joint SW/RN admission visit
  • Explore caregiver ability to provide care e.g. how exhausted is the spouse? Is he/she getting a good night’s sleep? Is respite care available? Is a hospice volunteer needed?  Is the caregiver still working?
  • Other key interventions on a first crisis visit include:
    1. Establish rapport/trust with patient and caregivers
    2. Create a list of phone numbers caregiver can call
    3. Intervene aggressively to relieve pain and dyspnea
    4. Simplify interventions based on caregiver need
    5. Alert all team members to intensity of need
    6. Ensure adequate emergency response time
    7. Complete a medication reconciliation
    8. Consider the use of a “comfort kit or emergency kit”
    9. Ensure patient and caregiver have agreed to hospice care and that hospice is there to ensure comfort until the very end.
    10. Educate on services and levels of care available for support
  • Coordinate with the prior treatment team for a smooth transition.
Crisis Management for a Currently Enrolled Hospice Patient
  • All staff should be trained in developing a therapeutic relationship and a therapeutic relationship should be established with each patient/caregiver.
  • Ask the patient and caregiver to describe their concerns and any steps they may have taken to address those needs.
  • Work closely with community providers and facilities whenever needed.
  • Identify the most problematic issues and develop a systematic approach to resolving them.
  • Identify specific service needs.
  • Ensure that the patient and caregiver are comfortable with the plan of care and have had the opportunity to review and make revisions to it.
  • Identify and document changes from the acceptable baseline.
  • Crisis assessments should be focused, brief and symptom oriented (including symptoms of spiritual distress).
  • Evaluate response to treatment.  Symptoms should be under control by end of visit. If not, Continuous Care or General In-Patient care should be arranged or initiated.
  • Provide education and information to patients and caregivers both on symptom management and emergency care.
  • An emergency plan should be consistent with the patient’s documented treatment preferences
     
Hospice Medication Management
Managing medications for a hospice patient has some unique aspects for the clinician. Skilled care requires both medication reconciliation and medication management. Because of the nature of hospice care and its focus on palliation, the clinician must be comfortable with procedures such as first dosing, titrating and tapering medications, changing from one form of an opioid to another (equi-analgesic dosing) changing the route of administration, use of PCA pumps and IV’s. Hospice clinicians must also teach and support informal caregivers on proper medication administration and management in the home. Also different from non-hospice care, hospice providers should be comfortable initiating conversations about discontinuation of medications not needed for comfort and palliation of symptoms. Medication Reconciliation
  • The hospice has a standardized medication reconciliation process in place that is completed and reviewed by the IDT within 5 days of the initiation of care.
  • Any discrepancies that are identified are clarified with the physician and/or pharmacy consultant within 24 hours.
  • There is a process in place to review current medications to determine which ones are related to the terminal illness and therefore the financial responsibility of the hospice.
  • Ask the patient/caregiver before the first visit to collect all of the patient’s medications and have them ready for the nurse to see. It is important to note any discrepancy between the prescription on the bottle and what the patient states he/she is taking.
  • Use the Verify, Clarify, Reconcile approach.
  • Ask about the use of non-prescription medications. Patients often do not volunteer that they are taking them.
  • Determine if the patient is self-managing or needs help in managing medications.
  • Identify any combinations of medications that may be contraindicated or medications that seem to be inappropriate such as those on the Beers Criteria. Identify potentially serious drug-drug interactions or therapeutic duplication. Identify patients who are on high-risk medications – antiplatelet medications, oral hypoglycemic, insulin, warfarin. Note if patients are taking “less-forgiving” drugs where non-adherence leads to adverse events or symptom exacerbations such as cardiovascular medications or anti-depressants.
  • Consider whether any medications could be discontinued, and with the patient/caregiver consent, consult with attending clinicians.
Medication Management
  • The hospice provides oversight of all medications that are prescribed for the patient.
  • The IDT maintains and reviews the drug profile of each patient on a regular basis.
  • The hospice assures immediate access to medications needed for prompt relief of symptoms that commonly arise in terminally ill patients.
  • Medication management training for RN’s should verify understanding of:
    • Medications effective for specific symptoms
    • Titrating and tapering doses to balance preferred effects with unwanted side effects
    • Using range orders for medications
    • The difference between round the clock versus PRN dosing
    • Which pills can be crushed and which can’t
    • Proper use of NG tubes or G tubes for medication administration
    • Recognition of categories of drugs that could potentially be discontinued at end of life
  • The RN reviews the patient’s medications on each visit to determine which medications are still being used, if any new medications have been added, and if any medications have been stopped or are not being used as ordered.
  • The RN should also assess the patient’s response to prescribed medications and assess for any side effects or adverse reactions.
  • Changes in medications, doses, route of administration etc are made in consultation with the hospice medical director and pharmacy consultant.
Page reviewed August 2019