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By Faith Protsman, MD, Regional Medical Director, VITAS HealthcareTwo recent studies highlight how sepsis impact often extends well beyond the acute event that led to a patients hospitalization. The studies emphasize two particular points that should inform physicians and clinicians as they consider referring these patients to specialized care: Medicare patient data gathered between 2012-2017 shows that sepsis patients face considerably poorer health outcomes following hospital discharge when compared to non-sepsis patients, including elevated risk for death and increased use of advanced healthcare services. Sepsis survivors exhibit strong indicators of persistent inflammation and immunosuppression for up to a year after hospital discharge, increasing their risk of readmission or death. Both studies indicate a significantly elevated risk of death among sepsis patients after they have been discharged and ostensibly cured. Of course, sepsis patientsparticularly those of the Medicare cohort, who are largely of advanced agerarely leave the hospital in better condition than they entered.The Yende study, in particular, shows that neuroendocrine and inflammatory responses to sepsis can continue long after the patient survives a septic episode. For patients with advanced or chronic diseasesas was the case with nearly 78% of participants in the studythese biomarkers are associated with decline.Post-sepsis Discharge: A Critical JunctureIn many cases, these individuals life expectancies upon discharge will be less than six months. This is a critical juncture: While comfort-focused hospice care could provide an ideal source of support for the eligible patient, their family, and their caregiver(s), most sepsis patients are simply sent home without even a discussion about palliative end-of-life care and its benefits.Frankly, such an oversight is a disservice to everyone involved. The sepsis patient is left with physical and/or cognitive dysfunction, often without significant options for symptom management. Their partner or family will either need to assume caregiving duties or turn to costly private services. And the physician and hospital staff will likely see the patient again following another acute event, a readmission that impacts performance scores, strains resources, and unnecessarily fills beds.By no means do I intend to lay the blame for these unfortunate circumstances on physicians. Timely hospice referrals require ongoing education about end-of-life care, and open, ongoing communication between hospice providers and referral sources.More Help: How to Talk About Hospice Care >Those of us in hospice are working hard to bridge the gap, but even as our healthcare system transitions to a value-based model, the mentality of fee-for-service still permeates our nations acute-care facilities, and many hospitalists see a discharge home as a success.Hospice: A New Way Of Judging SuccessIn hospice, we judge our successes on the patients quality of life and the fulfillment of their goals and wishes near lifes end. Usually, that means going home with 24/7 support from an interdisciplinary hospice team. Whether home is a traditional residence, an assisted living facility, or nursing home, the hospice team will assist caregivers (and/or facility staff) with direct clinical care and education, integrative services, bereavement support, and delivery of medication, equipment, and supplies.In other cases, improving quality of life means remaining in a general inpatient setting with hospice support, taking the burden off hospital staff until the patient is able to transition home or until the patient dies. Hospice offers complex modalities in any setting, so patients who would otherwise be confined to an ICU can usually return home to be among loved ones.With support from hospice, a sepsis patient and their family are more likely to report higher satisfaction of care and greater quality of life. The patients emotional and spiritual needs can be met alongside their physical needs, thanks to care from chaplains, social workers, music and massage therapists, and other integrative specialists. Finally, the patient is more likely to die at home, surrounded by loved ones, rather than in the hospital.Because sepsis is most common in patients with advanced or chronic diseases that indicate hospice eligibility, acute incidences of sepsis should always trigger a hospice eligibility assessment. We owe it to our patients, their loved ones, and our colleagues in healthcare, all of whom can benefit from the support that timely end-of-life care offers. 

By Faith Protsman, MD, Regional Medical Director, VITAS HealthcareVietnam War veterans face unique obstacles throughout the twilight of advanced illness. For hospice care providers to tailor care to meet the needs of veterans who have served in this theater of war, they must consider the tribulations these patients face as they reach the end of their lives.The Vietnam War era was a very tumultuous time to be a soldier. The United States' prolonged involvement in a war of questionable motivation left society with disdain toward the government and its institutions, especially the military.Coupled with horrific images shown on television, constant controversy was a new reality and negative public opinion formed around this conflict, of which those serving the nation were not spared.Careful consideration is necessary when treating patients facing these traumas.Tours of duty proved to be traumatizing in many ways. Young soldiers, some having just turned 18, were drafted into a war that many of them did not believe in. They were not fighting for love of country and God; rather, they were fighting for survival and out of fear for their lives.Intimate battles in the dense jungle led many to be subjected to the horrors that come with fighting in a foreign land that was only familiar to the elusive guerilla enemy soldiers.Servicemembers did not receive a warm welcome when returning home from Vietnam, often being judged and labeled as cruel and even inhumane.Moral Injury Can Impair Mental HealthThis perfect storm of trauma led to lasting moral injury that plagues many veterans for their entire lives. Veterans returning from the war were marginalized and pushed into isolation, often turning to alcohol and substance abuse, which worsened their anxiety and exacerbated their strife.Questions like Ive never spoken about the war, can I now? Was the war moral or immoral? and Was I a good soldier? come bubbling to the surface later in life as their illnesses intensify and their defenses weaken.Careful consideration is necessary when treating patients facing these traumas.The restlessness that can result from post-traumatic stress disorder (PTSD) is often treated with benzodiazepines. In most cases, these medications can bring relief through calming the patient.Yet, there is a common trend amongst veterans who cope with trauma that results in the opposite effect.Benzodiazepines can lower the walls that Vietnam veterans have built up throughout a lifetime of suppressing trauma and negative memories. This class of medications can exacerbate the symptoms of PTSD as traumatic experiences and feelings of regret resurface. Benzodiazepine-induced inhibition of neurotransmission can even lead to agitated toxic psychosis, increased anxiety, hostility, and rage.1The Value of Compassion Along with Clinical CareRemaining considerate does not end with simply staying mindful during the planning of clinical solutions. Providing care for Vietnam veterans requires a high level of empathy.A key to an empathetic approach is taking the time to listen nonjudgmentally. Though seemingly simple, practicing nonjudgmental, open communication with patients facing trauma from war can help avoid the all-too typical responses of Its okay and You did what you had to do.These patients do not need sympathy, because they have been judged enough throughout their lives. When care teams approach them without judgment, they honor the sacrifices these heroes have made.VITAS hospice care provides compassionate care approaches that are tailored to meet the distinctive needs of Vietnam veterans. With the Veterans Administration (VA) offering hospice care as part of its medical package, VITAS team members can provide empathetic psychosocial support, while utilizing clinical solutions that help manage symptoms.The qualifications for veterans to receive hospice benefits include: A life-limiting illness Treatment goals that focus on comfort, rather than curative treatments A life expectancy of 6 months or less, if their illness runs its normal course Veterans also benefit from the option to receive concurrent care through the VA. The VA can provide curative treatments as the patient simultaneously receives symptom-managing comfort care administered by the hospice care provider of their choosing.Offering solace, while remaining compassionate when patients need it most, is too often overlooked in the busy practice of healthcare. Acknowledging the adversity that Vietnam War veterans have had to face throughout their lifetimes and adapting care approaches to meet their needs is the best way for healthcare providers to give back to those who have sacrificed so much for the preservation of freedom.1Paton, C. (2018, January 2). Benzodiazepines and disinhibition: A review: Psychiatric bulletin. Cambridge Core. Retrieved November 2, 2022, from https://www.cambridge.org/core/journals/psychiatric-bulletin/article/benzodiazepines-and-disinhibition-a-review/421AF197362B55EDF004700452BF3BC6

By Dr. Lauren Loftis, Regional Medical Director, VITAS HealthcarePain and discomfort can be under-recognized and under-treated in patients with serious illness. At the end of life, 81% of patients cite being pain free as an important factor in dying a good death. 1 Along with the physiological pain associated with a patients terminal illness, anxiety and depression may contribute to their total pain. Social, emotional, and spiritual dimensions of total pain increase the patients suffering beyond their physical discomfort.A holistic approach to targeting pain at the end of life enables physicians to provide relief and comfort care that improve the patients quality of life.To illustrate, a patient Ill call Bob Jones is a 65-year-old male with stage IV colon cancer and extensive metastases to the bone, liver, and brain. Mr. Jones wife is his caretaker, and he is estranged from his son who lives out of state. His son does not accept his terminal diagnosis. Despite surgery, chemotherapy, and radiation, Mr. Jones disease has progressed.As I meet Mr. Jones for an initial hospice encounter, I ask open-ended questions, especially what matters most to him at this point in his disease progression, to determine his goals of care. I learn he is a Vietnam Veteran with signs of undiagnosed PTSD. He is constipated and desires to return home and spend time with his wife. He wishes to go to Hawaii but fears that this can no longer happen. His son does not want him to take morphine.Looking at the Total Picture: Optimizing Patient ComfortAs physicians, when we ask about pain, we keep in mind that it is defined by the patient. Hospice clinicians manage pain based on the needs and expectations of the patient and family, not our own.Getting an accurate measure of the pain level is necessary for appropriate treatment. The patient may be reluctant to report pain for fear of being a complainer or a desire to avoid opioids. Asking open-ended questions may help you gauge pain more effectively: How severe is the pain? Where is the pain located? What are you taking for the pain? How is that working for you? How is the pain affecting your ability to function daily, such as bathing, dressing, and the ability to get up and walk? Is the pain impacting your ability to fall or stay asleep? How is the pain impacting your mood? Is the pain impacting your ability to socialize or spend time with the ones you love? Other indicators of pain and suffering can be viewed or discussed. Dryness of the eyes can lead to painful keratitis as well as infections. Patients on long-term oxygen therapy may have skin breaks around the nares, dryness, and episodes of epistaxis, which can be distressing. Patients who have been using noninvasive modes of ventilation may have pressure ulcers at the nasal bridge and cheeks. Pooling oral secretions and lack of oral care can lead to oral ulcers and dental issues.Signs of malnutrition include temporal wasting, supra, infra-clavicular wasting, scaphoid abdomen, and skin dryness. Loss of muscle mass can create an increased risk of skin breakdown. Dehydration signs include dryness of mucosal surfaces, loss of skin turgor, and dry skin. Abdominal fullness can point towards constipation or urinary retention, which can cause significant distress to the patient. Lastly, a hygiene assessment and well-being focused on maintaining the patient's dignity are essential.For Mr. Jones, our VITAS team contacted his son to discuss his hesitation to provide pain medication for his father. Using a calm and thoughtful approach, we explored where his beliefs came from and if they were simply based on a common misconception about the use of morphine in hospice patients.Mr. Jones had agreed to hospice services to get out of this place, meaning the hospital, and go home to sleep in his own bed, with his wife and dogs nearby, his stated goals for end of life. He received Continuous Care to help manage his symptoms at home. The VITAS hospice physician evaluated him at admission and after transport to his home. Clinicians profiled his medications, which we arranged to be delivered to the home along with a bedside commode, walker, oxygen, and briefs.Managing Both Physical and Nonphysical PainOnce in hospice, the interdisciplinary teama team manager, primary nurse, hospice aide, physician, chaplain, social worker, team physician, and volunteercollaborates to address the patients total pain beyond opioids alone. VITAS also has an in-house pharmacy team with Pharm Ds on call to assist with symptom management consultations, medication selection, and dose conversions.After Mr. Jones arrived home, the home health aide gave Mr. Jones the first true bath he had had in weeks. The team addressed his constipation. We consulted our VITAS social worker and chaplain to help him and his family. The VITAS Pharm D assisted with a methadone titration regimen and pharmacologic selection.With these interventions, Mr. Jones felt so much better he couldnt believe it and wished hed called us months ago. He was able to live at home for nearly six months after his hospitalization. His course of symptom management allowed him to make meaningful memories with his family. He also achieved resolution to his estrangement with his son, which was not only significant to him but also the rest of the family, even beyond Mr. Jones death.Focusing on Quality of Life With Compassionate CareA total pain approach to comfort care minimizes any medication side effectseven those not related to the terminal illnesswhile enhancing the patients: Functional ability Physical well-being Psychological well-being Spiritual well-being This includes empowering the patient to participate in decision-making, which helps them retain dignity and a sense of control.The emphasis of comfort care is to improve the patients quality of life in their remaining months, weeks, and days. The outcomes of the hospice interdisciplinary care teams efforts are evidentin the photos we receive and the kind words of family members and even patients themselves who entrusted their care to us. Like Mr. Jones, many tell us: We wish we knew about hospice sooner.Questions about total pain management? Ready to refer a patient? Contact your VITAS representative. 1Meier, Emily, et al. (2016). Defining a Good Death (Successful Dying): Literature Review and a Call for Research and Public Dialogue. American Journal of Geriatric Psychiatry. Retrieved Sept. 16, 2024