VITAS Healthcare

By Dr. Valerie Hart Quezada, Team Physician/Geriatrician, VITAS HealthcareIf we believe in stereotypes, older adults are all the same. Yet this fast-growing population is very complex and diverse. They defy a simple description because chronological age is not the same as physiologic age.Both Sylvester Stallone and Arnold Schwarzenegger are in their late seventies while living robust, active and independent lives. Contrast this with a frail individual of the same age living in a nursing home with balance and mobility issues who relies on support for daily living activities.Approaching the Older PatientBecause we age in different ways, its important to know as much as possible about the patient we are treating and cultivate skills to match care to their health, functional status, priorities, and life expectancy. It is not enough to know age and comorbidities only.The baby boomer population is living longer yet doing so with chronic illnesses. Often, health professionals are not well prepared to care for patients with multiple chronic conditions and have a harder time understanding disease trajectories. The silver tsunami of 73 million individuals in the US will require the mindfulness and holistic care of clinicians.Physiologic vs. Chronological AgeThe normal aging process produces an increase in hearing and vision issues, frailty, sleep disturbances, urinary tract infections (UTIs), potential falls, gait and balance issues, and osteoporosis.How the body manages these changes will depend more on physiologic age than chronological age.Chronological age is the number of years, months, days since birth.Physiologic age is the patients functional age based on their lifestyle, diet, exercise or fitness level, and even education.When aging, cellular and molecular damage contribute to a decrease in physiologic reserve, or the bodys ability to withstand stress and recover from illness. The loss of muscle mass, increase in cortisol, and changes in hormones and blood pressure can affect homeostasis. With decreased physiologic reserve, small insults can result in significant decline. A new medication can lead to acute renal failure. Contracting pneumonia can turn into respiratory failure. A minor illness or even dehydration can produce delirium.Suppose an 85-year-old who is robust, independent, and perhaps still driving gets a UTI. They may experience a dip in functionality but can likely recover quickly. Another 85-year-old who is weaker and frail may also acquire a UTIand may not be able to recover to baseline.Applying the 4Ms to Determine Health Status and GoalsDeveloped by the Institute for Healthcare Improvement, the 4Ms help healthcare professionals gauge the status of their patients. They are:Mentation, which is the patients presentation of dementia, delirium, or depression. What is their mental state? Do they have cognitive challenges or are their typical age-related responses?Mobility or their ability to get around. Do they use a cane or rollator? Do they need to? Older adults value being independent, so we need to identify when they start to become frailer and find ways to address barriers to being more active.Medications: Review these and identify what does not belong and discontinue. Ensure they understand the medications they are taking. Also, can they manage their medications?What matters most? Asking this question will help you identify what their values and goals are. These may vary by cultural or religious affiliation, life experiences and diseases. Do they want to be more active? Spend more time with family? What will help them achieve what matters most to them?A fifth M can be multimorbidity if the patient is experiencing several chronic conditions.Open-Ended Questions: What HCPs Can AskRemember that most older adults do not want to become a burden to loved ones. When they express this to us, it is a good place to start the conversation. This is an ongoing discussion because it can change for the patient over time, as their serious illness progresses. Here is a sampling of questions:What do you think is going on with your health? This enables physicians to prognosticate.What do you think the healthcare system or I can do for you? Identifies the patients expectations.Is there something you want to do in the future? Or, what activities do you find enjoyable that may have been disrupted? Physical therapy may help them increase their abilities.Who is important in your life? How often do you see them? This can reveal social deficits and isolation.Are you able to care for yourself? They may not reveal deficiencies unless asked. Minor interventions can help.Once assessed, acting on these responses can help us align the care plan with what matters most to the older adult. If opting for hospice and palliative care, the patient receives wholistic care that includes medical, psychosocial, and spiritual support. Sharing information about the Medicare Hospice Benefit, which covers 100% of hospice services under Medicare Part A, can ease the patients mind about financing this type of end-of-life care.Respect: The Key to SensitivityOlder adults are experts on aging, and it helps to show them sincerity and empathy. Because they sometimes experience ageism from their community, the healthcare system, or even their own family, they may not receive the care they need.Breakdowns in care may happen when healthcare professionals assume all older adults are the same or focus only on the medical instead of the whole person. The cognitive/emotional, familial/social, environmental, and financial domains are interconnected. Taking this whole-hearted approach will help healthcare professionals provide care that enhances their quality of life.Do you have a patient with serious illness or multiple morbidities? Could it be time to have a goals of care conversation? For assistance with this conversation or questions about hospice-eligibility, contact VITAS.

When 18-year-old Abraham Maldonado confided in Chaplain Antonio Rivera-Maldonado (no relation) that he wanted to attend his high school graduation ceremony, Antonio immediately shared that wish with the rest of Abrahams hospice team.Abraham, a VITAS patient in Orlando, Florida, has lived with malignant neoplasm (a cancerous tumor) of the spinal cord for a decade and may only have another six months to live. Despite battling his illness, he has continued attending high school through a virtual learning program at home.Only a few credits shy of completion, Abraham wanted to attend his graduation and celebrate his accomplishment.The moment Team Manager Nicolette Burton heard about her patients final wish, she agreed: They had to make it happen.Abraham doesnt like to complaineven when hes in pain, Nicolette says. Despite everything hes been going through, he has such an outgoing, positive, can-do attitude. I wanted to do anything I could to help make his dream come true.A Dream RealizedThanks to Antonios work, Abraham was granted his wish. A private ceremony was held in the Boone High School auditorium in Orlando. With his family, high school friends, VITAS interdisciplinary team, and Boone High School staff in attendance, Abraham received his honorary high school diploma.It feels good to know that I could make a difference in his life.-Werner Ferman, VITAS LPNOriginally from Puerto Rico, Abrahams family has made many sacrifices to ensure he receives the best care possible.[He] is a gift. With support and love, his family rallies around him, Social Worker Lisa Camacho says. Theyve never once made him feel like hes a burden. They love him. His condition is only a part of who he is. Theyre running alongside him with comfort and support as he continues his unique journey on Earth.Finding the Strength to PersevereAbraham worked hard to achieve his goal, and it was far from easy. The daily hurdles and obstacles were challenging.At one point, as much as he loved learning, it was becoming difficult to find the strength to continue.Abraham was frustrated and did not want to go back to school. He almost gave up. says Antonio. So, his father made a deal with him. If he went back to school and finished, his [dad] would go back to school, and they would graduate together.Today, Abraham is a high school graduate. And on July 10, he attended his dads graduation ceremony for a bachelor of science degree in mechanical engineering.It was great to be there for Abraham on his special day, says Werner Ferman, a licensed practical nurse on Abrahams team. Hes a warrior and a champion! I dressed up as the VITAS mascot and cheered him on as he received his diploma. It feels good to know that I could make a difference in his life, providing care that enabled him to achieve his goal and dream.Despite numerous struggles, 18 surgeries, and years of chemotherapy and radiation treatments, Abrahams personal life quote is, Never give up! says Nicolette.Abraham and his family celebrated his dads college graduation just a few weeks after Abrahams high school graduation ceremony.

By Dr. Joseph Shega, Chief Medical Officer, VITAS HealthcareHospice provides myriad benefits to patients nearing the end of life: improved quality of life, better symptom and pain control, and greater patient and family satisfaction. However, despite increases year over year in the number of beneficiaries who used the Medicare Hospice Benefit, hospice remains underutilized in some patient populations. Two such populations present an opportunity for improvement: inpatients placed on Comfort Measures Only (CMO) and patients of color. Both groups face unique barriers to accessing hospice care.The Need for General Inpatient Hospice (GIP) Among Comfort Measures Only (CMO) PatientsMost hospice care (more than 98%) occurs in the home, whether a private residence, assisted living community, or nursing home. However, when a hospice patients symptoms can no longer be managed at home, they may move to a General Inpatient Care (GIP) setting for a short period of time to manage acute symptoms and pain. Despite being one of the four levels of hospice care required by Medicare-certified hospice organizations, GIP care remains uncommon. According to National Hospice and Palliative Care Organization (NHPCO) data, in fiscal year 2022, GIP comprised only 0.88% of Medicare days of care.1This need for an enhanced level of care is particularly evident when examining hospitalized patients on Comfort Measures Only (CMO), or comfort carea population that may widely benefit from being admitted to GIP care to manage their pain and other symptoms before returning home to receive routine hospice care.A 2023 retrospective cohort study by Kozhevnikov et al. showed that around 22% of studied patients who transitioned to CMO status during their terminal hospital admission received general inpatient hospice care before death.2 CMO decedents who died without GIP during their terminal hospitalization were more likely to die in an ICU, have a lower Rothman Index (i.e., a higher risk of adverse events, clinical deterioration, and worse outcomes), and spend less time with CMO status.2 Further, without hospice care, families do not receive the 13 months of bereavement support that hospice provides after the patients death.Improving access to GIP hospice care among patients on CMO and awareness among care team members will result in more patients being able to benefit from the specialty symptom management, treatment of psychological and spiritual distress, and bereavement support that hospice can provide.Underutilization in Minority GroupsAlong with the barriers faced by CMO patients, racial disparities play a significant role in the underutilization of both palliative and hospice care, particularly among minority groups.A 2024 study by Cid et al. found that minority patients were less likely than White patients to have documented end-of-life care during terminal hospitalizations.3 Using palliative care encounters and do-not-resuscitate (DNR) status as metrics for end-of-life care, the study showed that, compared to White patients, Black patients were 17% less likely to have palliative care encounters and 9% less likely to have DNR status.1Going beyond this study's metrics, racial disparity can also be seen in hospice utilization. The NHPCO found that among Medicare decedents in 2022, hospice use occurred in 51.6% of White Medicare decedent beneficiaries, but among only 38.3% of Hispanic decedents, 38.1% of Asian-American decedents, 37.4% of Black decedents, and 37.1% of North American Native decedents.1Improving these metrics may begin with goals-of-care conversations. Initiated by clinicians, these conversations help uncover a patients wishes, values, and care preferences. From these discussions, we can help inform patients and their families about their options for end-of-life care, including hospice.It is our duty as clinicians to have these conversations early and often with our seriously ill patients and their families, so they are well-informed of the care choices available as their disease continues to progress. Healthcare professionals should ask open-ended questions to understand what matters most to patients facing serious illness.For minority groups, approaching these conversations in a culturally sensitive and respectful manner is paramount. This may include considering language preferences, understanding specific cultural or religious beliefs around illness and death, and involving family members in the decision-making process.An Opportunity for Change and ImprovementOver the years, hospice awareness and utilization have grown, but it remains underutilized among terminally hospitalized patients on CMO and patients of color. These two unique populations present their own challenges and opportunities regarding access to hospice, highlighting the need for effective goals-of-care conversations to increase hospice awareness and accessibility.By fostering culturally sensitive conversations that increase awareness of the Medicare Hospice Benefit, we ensure that patients and families from all backgrounds have the option to receive the compassionate, equitable end-of-life care they deserve. These efforts will help bridge disparities and improve the quality of care for countless individuals and their families.1. National Hospice and Palliative Care Organization. NHPCO Facts and Figures. 2024. Available from: https://www.nhpco.org/hospice-facts-figures [Last accessed: September 11, 2024].2. Kozhevnikov D, et al. Factors associated with inpatient hospice utilization among hospitalized decedents with comfort measures only status. Journal of Palliative Medicine. 2023;26(8):1048-1055. doi:10.1089/jpm.2022.04603. Cid M, et al. Disparities in endoflife care for minoritized racial and ethnic patients during terminal hospitalizations in New York State. Journal of the American Geriatrics Society. Published online July 10, 2024. doi:10.1111/jgs.19046

A glance at the July cover of the Martin County HUGS DEMENTIA magazine shows a beaming artist with a paintbrush. Readers cant see beyond the image to the life journey of the woman peering back at them.She is Sharon Cook Jankowski, a teacher and photographer, a sister and mother. Sharon shared her artistic talents with high school students, developing close ties with them, some of which lasted a lifetime. She also was a light to many who came to know her.Before embarking on a nine-year odyssey through Alzheimers disease, which brought her into hospice and the comfort of the VITAS Healthcare team, Sharon devoted herself to those around her.Sharons greatest love, besides raising her daughter Moriah, was serving God at her church, says Sharons sister, Gail Winsor. As a volunteer, Sharon used her talents to teach new believers, participate in worship and dance, and help feed and clothe the homeless, stretching far beyond her own community.Her life was always about helping others, said Gail.When Alzheimers AppearsAt the age of 55, Sharon began experiencing symptoms of Alzheimers disease. She gradually lost the ability to engage in the activities that made her life so vibrant. After three years, she moved in with her sister Gail in Florida.I had to make a tough decision. I called VITAS hospice.Eventually, Sharon replaced her previously joyful pursuits with a new one: attending the Alzheimers Community Care in Stuart, Fla. She truly believed she was going to work to help the others there, Gail says, reflecting Sharons continuing desire to support others.It was during this time that the magazine editors asked Sharon to be their feature story. They could see Sharon lighting up the day care center and wanted to spotlight her.The issue was released more than a year after Sharons interview and photo session, due to the lag time in print publication. By then, she could not recognize her own face on the cover.Facing a Rapid DeclineSharons light grew dimmer. Delusions and hallucinations made her feel like a prisoner in her own body, said Gail. I had to make a tough decision. I called VITAS hospice.The VITAS interdisciplinary team in Floridas Treasure Coast moved Sharon to an inpatient facility to regulate her medications. The goal was to shift Sharon back home with the teams assistance and appropriate equipment.Nine days in, I learned Sharon would not be coming home, said Gail. My heart was broken.Compassionate Care as the End NearsTeam members offered support to Gail while comforting and caring for Sharon.These loving, caring people got me through the last thirteen days of my sisters life. The hospice angels allowed my sister to pass with dignity, says Gail. She was so well cared for. I never could have done it at home. My emotional needs were cared for, too. They truly cared about both of us.Sharons journey with Alzheimers ended on August 8, 2021.Sharon went home to be with the Lord, says Gail. Thanks to VITAS, I was with her as she left her earthly being. One of the nurses who was not working that day ran over when she heard. That is true caring.Bearing the GriefThough Sharon passed, the VITAS Treasure Coast team continued to reach out to Gail.The most amazing [gesture] was when I got a phone call offering to make bears out of Sharons clothing, says Gail. I met with Daily Martinez, volunteer services manager. The love, respect, and attention to detail she showed me was so comforting. I knew I had given the right person the clothing I treasured from my beloved sister Sharon.My emotional needs were cared for, too. They truly cared about both of us.Daily felt honored to be part of Gails experience. Without ever knowing she would be involved in her story, Daily read the feature article on Sharon and shared it with family members.I will forever treasure the love shared between these two sisters, says Daily. I am so grateful that Gail and I were placed in each others path for the important purpose of keeping a loved one's memory alive. The Memory Bears are a beautiful reflection of the joy Sharon brought to the world. Her smile and beauty will be remembered.Gail received two bearsone for her and one for Sharons daughter, Moriah.I cant explain the feeling I got when those bears arrived, says Gail. Mine lays on Sharons bed. It is so comforting to feel her there with me. I am also so thankful to Carrie Dantzler, the VITAS Memory Bear seamstress, whose beautiful creation is helping us with the healing process.

JC Payne, a VITAS patient in Floridas Treasure Coast, had been unable to spend quality time with his wife for more than two years due to the nature of his illness. And now, he was reaching his last opportunity to leave an everlasting happy memory that she could keep with her after he died.JC had discussed his love for fishing with Andrew Mee, VITAS massage therapist, many times during their sessions. When he mentioned that he would love the opportunity to be on the water one last time with his wife, Andrew contacted VITAS Team Manager Darlene Billington.Honoring last wishes is just one way VITAS can support patients with quality of life near the end of life. VITAS interdisciplinary care teams, including social workers and nurses, provide the care best suited to meet each patients specific needs.I Hear Celies LaughterJC had always been passionate about fishing. For him, it provided an opportunity to bond with loved ones through an exciting, engaging, and rewarding activity.From the struggle of reeling in a difficult catch to the moment of relief and excitement that comes with finally getting the fish in your hands, its the ups and downs of angling that made it such a fun way for JC to make memories with those closest to him.JC Payne greets his wife on the day of the fishing trip.JCs wife, Celie, has coped with paralysis but continues to live in the Payne family home. JC had been living in a nursing home, receiving end-of-life care for his chronic illness. VITAS Social Worker Shekina Burson was able to coordinate transportation for Celie, and the fishing trip was planned to be at a lake near JCs nursing home.On the day of the trip, JC was excited, lively, and as personable as ever. His VITAS care team knows him well; with his friendly personality, they're always in for a fun time when they see him.Once he arrived, it was all smiles from the start. Celie relies on a wheelchair as a result of her condition. When she was being wheeled down to the dock, JC, without seeing her, stopped and said Wait, I hear Celies laughter.This was a heartwarming moment for the entire team, and it was beautiful to see their warm embrace. They were elated to see each other after having spent so much time apart.Throughout the afternoon, they enjoyed fishing, having lunch, sharing great conversation, and reminiscing with not only each other but also the entire group that attended. What If the Fish Arent Biting?At left, hospice patient JC Payne with members of his VITAS care team; at right, JC poses with a trout bought especially for the trip just in case the fish weren't biting.Volunteer Services Manager Daily Martinez helped to plan JCs special trip. She anticipated that the fish may not be biting that day; it is, after all, fishingnot catching.She had purchased a few trout at the market for a photo-opportunity with JC and Celie. The goal was to capture their success on the fishing trip, but JC, being the sharp-minded lifelong angler, recognized the trick immediately.The bait and switch with the trout became a joke that left JC, Celie, and the whole team laughing throughout the rest of the experience.JC was grateful that the VITAS team spent the day with him doing something he loves. The entire team involved was also immensely grateful to him for sharing this special moment with them.JC and his wife Celie enjoy a quiet moment together near the water.Both JC and Celie enjoyed an afternoon of angling, lunch, and laughter.

To show honor and respect to the veterans of Charter Senior Living in Gainesville, Florida, VITAS unveiled a veteran wall of honor in July. The memorial wall features the names and pictures of residents who have served in the U.S. military during World War II, the Korean War, and other armed conflicts.We want to serve those who served us first.-Christina Coffield, VITAS representativeThe event featured a ribbon cutting by the Gainesville Chamber of Commerce and a pinning ceremony led by Officer Patrick Treese, a Coast Guard veteran and head of Newberry High Schools Academy of Criminal Justice, along with the up-and-coming generation of service members.The following veterans received pins:William Evans, National GuardJacob Feaster, Army & Air ForceWilbur Groves, Air ForceNorman Hallock, ArmyRobert Bruce Jones, NavyJerome Leyendecker, ArmyAnthony Messina, Marine CorpsJohn Saffer, NavyFred Snellgrove, ArmyRichard Wheeler, Army & NavyIn proxy, Rosalie Spada, who is the oldest living Korean War female Marine, also received a pin.Making It PersonalWilliam Evans, who served in the National Guard, receives a pin for his service from criminal justice student Keegan Lowrey.Christina Coffield, the daughter of a veteran and the VITAS representative who led the event coordination, said: Gainesville veterans are close to our heart. During the pandemic, we partnered with students who wrote 4,000 letters expressing their thanks to veterans for the freedoms they enjoy today. We want to serve those who served us first.Echoing this sentiment was Angela Hamrick, general manager for VITAS in the Nature Coast."At VITAS, every day is Veterans Day, said Angela. Our experts are trained to help meet the unique needs veterans face as they near the end of life, and our dedicated hospice teams provide compassionate care to improve their quality of life. Through pain and symptom management, VITAS can help them make the most of their remaining time."Other VITAS team members showed their appreciation and regard for the sacrifices of these veterans by attending the ceremony, including Director of Market Development Donald Bussey, Rep Isaiah Brinza, Volunteer Manager Lynda Schladant, and Army veteran volunteer Lacey Wallace. Recognition on a Statewide LevelCommunity and state leaders also joined the day's events to honor the veterans.Dirk Frazel, regional field director for the Republican Party of Florida, read a letter of commendation from Governor Ron DeSantis and Senator Marco Rubio for VITAS' work in honoring and upholding the community's veterans.Following the presentation, representatives from the Veterans Administration offered education to veterans and their families on how to maximize their benefits. VITAS partners with veterans to determine benefits and serves as a resource for advance care planning, including for those who are not patients.Since 2019, the Gainesville community has welcomed VITAS hospice teams in delivering compassionate care to patients and their families at home throughout Alachua County and the Nature Coast.VITAS Rep Christina Coffield (center) poses with Executive Director Christine Rodriguez (L) and Director of Health and Wellness Raven Monroe, RN, of Charter Senior Living.Gainesvilles VITAS team (from left): Lacey Wallace, Army veteran volunteer; Lynda Schladant, volunteer manager; Christina Coffield and Isaiah Brinza, VITAS reps; and Donald Bussey, director of market development.

From the cramped cabin of the aircraft, VITAS Healthcare patient Kim peered out through the open door and took in the landscape.In the next moment,shewas dropping from 10,000 feet, reminding her senses: You are alive.Kimcouldnt help but smile. She had made a habit of seeking these reminders throughout her 64 years on Earth. Now, as she neared the end of her life, the message seemed to come through with renewed clarity as her wish to fly through the atmosphere one last time came true, thanks toher VITAS hospice team.It takes a lot of coordination, but when you have a whole team coming together, you can make anything work, says Daily, VITAS volunteer services manager.ToKim, cirrhosis of the liver seemed at first like a challenge waiting to be overcome. After all, she had raised a son as a single mother, worked on a farm, and been involved in community politicsshe understood perseverance. But after receiving a terminal prognosis and beginning care with VITAS,Kimstarted to focus on what she could feasibly achieve in the time that remained.Id been seeing Kim for about eight months, and one day she mentioned that shed been skydiving in the past and wanted to do it one last time, says Tammy,Kim'snurse.Dailysuggested that virtual reality (VR) could offer a simulated version ofKims desired experience without the risks associated with jumping from a plane. The VITAS team manager and physician agreed.On the day of the skydive, Kim was joined by Tammy, Daily, and other members of the VITAS team in her home. One of the nursesstood ready with the fan asKimsat down and donned an Oculus Rift VR headset. What followed was a beautiful experience for everybody.At one point,Kimstood from her chair, ecstatic with the sheer sensation of it all. After landing safely on the ground, she immediately began showering the team with appreciation.ForKim, the experience was clearly a dream come true, but not quite a replacement for the real deal:Tammysays that her patient still jokes about skydivingand bringing her favorite nurse along for the ride.Written By Bob Johnson, RN, general manager for VITAS Healthcare in Collier County- click here for more information**

Your patient with advanced lung disease is on multiple medications, prone to exacerbations, in and out of the hospital. Family caregivers are stressed, the patient needs increasing assistance with activities of daily living. The family calls your office, 9-1-1, and the hospital.VITAS can help. We have the resources to keep your high-risk, hospice-eligible ALD patient at home and comfortable during a crisis, day or night, and relieve the cost burden to the patient and their insurer. Lets talk about the VITAS services that can make a difference.What Does VITAS Offer?MedicationsProactive clinical approach that enhances quality of life and symptom managementRelated medications are covered at no additional costCollaborate with PCP and/or pulmonologist on plan of careMedications*: corticosteroids, mucolytics, antitussives, bronchodilators and other related medicationsAntibioticsIV fluids*/hyperdermaclysis*/other program-specific treatment modalities*Home-based education regarding medication administration to maximize efficient delivery bronchodilatorsIntensive management of dyspnea, anxiety and other symptoms*Requires clinical case discussion between the VITAS medical director and attending physician.HME/suppliesProvide necessary equipment for patient safety, quality of life and caregiver supportFinancial burden of high costs is relievedNebulizersBiPap, CPAP or other non-invasive ventilationOxygen, including high-flowWheelchair, shower chair, bedside commodeto help with energy conservationHospital bed, over-bed tableMattress variations to reduce skin breakdown (including low-air-loss mattress)Hoyer lift for safety of transfers, energy conservation & caregiver assistanceDiapers, barrier creams, gloves, wound care suppliesHigh-acuity levels of careTelecare: 365/7 and weekends. Live clinicians, triage, after-hours and emergency callsLicensed clinicians have real-time access to the patient EMR to best support patient/family/facility through a respiratory crisis. If needed, the clinician will also dispatch a nurse to patient home.After-hours clinicians: Designated nurses who respond to after-hours and emergency calls.Intensive Comfort Care (continuous care): When a change in condition or acute respiratory exacerbation requires intensive symptom management, VITAS is able to provide, on a temporary basis in the home, a licensed nurse and/or HHA at the patients bedside per Medicare guidelines.General Inpatient Care: Intensive symptom management on a temporary basis when acute respiratory exacerbation or change in symptoms cannot be managed at home.Complex modalitiesOxygen: Back-up O2 tanks for emergency power outages, high-flow and liquid oxygen with option for Venturi & non-rebreather maskVentilator removal supportTracheostomy (non-ventilator-dependent)BiPAP, CPAP or other non-invasive ventilationThoracentesis*Pleurex drainsRespiratory therapist*Dietician supportTherapy services*: PT, OT, speechOnly if appropriate and approved by VITAS medical director. May be program-specific. Check with your program.Care teamHospice Aide: Based on individualized plan of care: bathing, dressing, feeding, etc.Nurse: Symptom management, medication review, disease-specific educationPhysician: Collaborative support with PCP/pulmonologistVolunteer: Life review, friendship, reading books, QOL activitiesRespite care: For caregiver burnout/relief up to five daysChaplain: Non-denominational support, discussions providing closureSocial Worker: Family meetings, counseling, facilitating reunions, access to community resources, help with emotional suppressionRespiratory Therapist: Pulmonary hygiene, teaching, supportAlternative Therapy: Massage, music, pet visits*Patient/family educational resources that energy conservations techniques, meditation, depression, anxiety, oxygen safety, advance care planningOriginally published August 4, 2017 and updated October 9, 2024.

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 abilityPhysical well-beingPsychological well-beingSpiritual well-beingThis 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

If youre like most Americans, you prefer to age in place in your own home. Thats why hospice services come to residents in assisted living facilities (ALF)to enhance the care they are already receiving. VITAS Healthcare, the nations leading provider of end-of-life care, is proud to recognize National Assisted Living Week: September 915, 2018.ALFs are designed to feel as much like home as possible. Residents enjoy comfortable surroundings, social activities and home-like amenities, with some receiving help with dressing, eating, personal care and hygiene, as well as daily monitoring for select chronic diseases like heart disease, Alzheimers disease, depression and diabetes.Hospice care in the ALFIf an individual becomes eligible for hospice care, an interdisciplinary VITAS team works with the resident, his family and physician, and ALF staff to implement a care plan that supports comfort, pain relief, symptom management and quality of life at the end of life.A VITAS hospice teamdoctor, nurse, aide, chaplain, social worker, bereavement specialist and volunteerbrings compassionate care and medical expertise to the ALF resident at the bedside, addressing physical, psychosocial, emotional and spiritual needs.Compassionate care from a hospice teamCovered 100% by Medicare, Medicaid and most private insurance plans, patients pay nothing out-of-pocket for hospice team visits, medical equipment, medications and supplies that are related to the terminal illness and delivered to the ALF.VITAS, celebrating its 40th anniversary in 2018, also provides specialized services, including Paw Pals pet visits, music therapy and massage therapy. VITAS teams recognize the unique experiences of veterans and provides culturally sensitive care for Latino, Asian, Haitian, African American, Jewish and LGBTQ populations. When an ALF resident passes away, VITAS provides bereavement services and grief support to the family, staff and other residents for up to a year.If an ALF is home, VITAS can provide the hospice services that will enable residents to live, age and die in the comfort of their own home. In honor of National Assisted Living Week, thats comforting to know.For more information about hospice care or end-of-life care options, call VITAS Healthcare at 866.759.6695 or visit VITAS.com.

It takes time to deliver to patients all that the Medicare Hospice Benefit offers.Americas hospice programs are being rushed. Short-stay patients, those referred for hospice care mere days before death, typically are in a state of acute medical, emotional and family trauma. Hospices only have time for emergency medical response, family crisis intervention and hurried attempts to maximize quality of life in the few precious days before the patient dies.Although the Medicare Hospice Benefit is intended to provide comprehensive, quality care to those who are expected to live six months or less, half of all hospice patients nationwide receive only three weeks of care before they die. A third of hospice patients receive care for less than one week, according to the National Hospice and Palliative Care Organization.That crisis-management approach is in sharp contrast to the hospice ideal: building trusting relationships; controlling distressing symptoms such as pain; encouraging meaningful emotional closure for loved ones; and facilitating a peaceful dying experience for the patient and grief support for loved ones.As important as crisis support is, hospice is about living. While hospice can work miracles when someone is referred in crisis, we can do so much more for patients and families if we're given three weeksor better yet, three monthsinstead of three days to provide care. The more time the hospice team has to support the patient and family, the better the quality of life for the patient and the better the memories for loved ones following the death.Customizing care to meet end-of-life needsHospice interdisciplinary team members care for each patient as an individual; his or her needs always come first. That kind of service reduces family calls to their physicians office and prevents unnecessary trips to the emergency department. And hospice provides timely communications to patients physicians, adds Joel Policzer, MD, VITAS senior vice president and national medical director, so they are never out of touch.VITAS Telecare support ensures that the patient and family have 24-hour direct access to experienced hospice staff, adds Policzer. Just a phone call away, these professionals can be a reassuring voice at 3 a.m., and they also can assess, advise and dispatch clinicians in moments.When there is a crisis or a spike in symptoms VITAS Intensive Comfort Care staff offer up to 24 hours per day of medical management in the patients home, where most people hope to remain at the end of life.Caring for body, mind & soulWith time to get physical pain under control, there also is time to evaluate psychosocial pain. Patients often learn to embrace this important stage of life, making connections, repairing relationships, rediscovering simple pleasures and making their peace with death, says VITAS Social Worker Lori Reardon, MSW. Hospice helps patients live each day.When the end comes, VITAS goal is not to let any patient face death alone, Reardon adds. Members of the team gather to be with their patient and to support loved ones at the final moments, and for a year or more after-ward. We help families to grieve, to live and to remember.By Pippa Steinhart, RN, General Manager, VITAS Innovative Hospice Care of Collier County. VITAS works with healthcare professionals in Collier County to bring quality of life to patients at the end of life. For more information, contact VITAS at 866.928.4827

Vietnam veteran Michael Badeaux was among Dr. Angelica Torress first patients when she joined VITAS in 2021. Over the next two years, she became his regular physician, his speed-dial contact, and his friend.She felt firsthand the impression he made on everyone who cared for him. As he approached the end of his life, she felt moved to ensure he received special recognition for his service.As the most clinically complicated patient case on my team, it is difficult to summarize two-plus years of laughs, tears, and silences, Angelica said. I really appreciated him, not only because he was such a brave veteran but because he had a very sweet heart full of love.VITAS always recognizes patients who have served in the United States Armed Forces. One impactful way we ensure they feel this appreciation is the bedside salute. Traditionally, one bedside salute is carried out as a veteran patient is reaching the end of their journey through life. However, because of the extended time he had spent in hospice care, Badeaux received a second bedside salute coordinated by Angelica and other members of his care team.As a private first class in the United States Army from 1969 to 1971 and a Vietnam War combat veteran, Michaels courage in adversity extended beyond his military service, said Nancy Auster, VITAS community liaison for veteran affairs.Michael has been through a whole lot with his disease over the past two years, but he still has found ways to touch our hearts throughout the journey, Nancy said. It is because of his kindness, despite a situation that calls for tremendous bravery, that we mutually decided he should be saluted a second time.The VITAS bedside salute ceremony lasts about seven minutes, during which a curated set of itemsa blanket, an appreciation certificate, service recognition pins, and a thank-you cardis presented to the veteran.Angelica and other members of Michaels care team attended the ceremony alongside former servicemembers from the local American Legion post and a contingent of Veterans of Foreign Wars members. Chief among these was Jesus Gutierrez, a fellow Vietnam veteran and Purple Heart recipient, who shared a special moment of recognition with Michael during the salute.Michael Badeauxs bedside salute stands as a testament to the profound impact of VITAS patients on the people who care for themand our care providers responsibility to ensure every patients life is understood and honored before the end.Mr. Badeaux was very appreciated and loved by our team, Angelica wrote in an email after the ceremony.For our patients whose service to our country is nothing short of extraordinary, our commitment to recognizing their sacrifices goes beyond the ordinary; it is a steadfast promise to care for veterans with unwavering respect and gratitude.

When it comes to personalized care for our Jewish patients, VITAS teams provide culturally sensitive, compassionate hospice care that respects the teachings, beliefs, rituals, and traditions. Our specialized care offers hope, honors the core principles of Judaism, and is guided by the religious preferences and cultural practices.We know that families practice their faith along a spectrum of observance to Jewish traditions, says Charlotte Goldberg, RN, BSN, a home care nurse and Jewish educator for VITAS in South Florida.At VITAS, our care teams make every effort to be mindful of the basic rituals and traditions of Judaism. We respect patient and family concerns about artificial nutrition and hydration, as well as Jewish ethics and philosophy surrounding life and death.As hospice professionals, we gather information and create compassionate care plans that address expectations and respect each patients and familys traditions around end-of-life care, grief, burial, and mourning, Goldberg says. We work with each patient and family to explore any misconceptions they may have about end-of-life care and explain how hospice care aligns with their Jewish laws and teachings.Committed to Personalized CareCharlotte points out that whether patients practice Judaism along Reform, Orthodox, or Conservative ideologies, or consider themselves to be Secular Jews, the VITAS goal remains the same: We are committed to personalized care that offers hope, values life, embraces kindness, and is enhanced by each Jewish patients and familys preferences.VITAS includes key questions during the patient admissions process:How do you practice your Jewish faith? What is important to you and your family?What can we do as a hospice team to meet your needs and preferences for care near the end of life?Which Jewish traditions do you want your VITAS team to understand and honor regarding the practice of prayer, food preparation, and holiday observances?What are your preferences for memorial services, mourning, burial, and continued bereavement support?Does your loved one have a personal connection to the Holocaust? If so, would you or your family benefit from additional support, counseling, or spiritual assistance?Similarly, VITAS chaplains support Jewish families in multiple ways, including asking which prayers and rituals they prefer. Chaplains can also work with the family's own rabbi, or a volunteer community rabbi if they feel more comfortable with religious leaders of their own faith.We work with each patient and family to explain how hospice care aligns with their Jewish laws and teachings.The goal of hospice care is to provide hope for a peaceful, patient-centered end-of-life experience and for a familys ability to mourn constructively through sensitive grief support, Charlotte says.Some VITAS care teams also pursue additional external accreditation by the National Institute for Jewish Hospice, a third-party designation which qualifies caregivers to provide sensitively informed care to patients and families on their end-of-life journey.All care team members go above and beyond to understand our Jewish patients and families needs and uphold the VITAS commitment to provide culturally appropriate, sensitive care.

From the cramped cabin of the aircraft, VITAS Healthcare patient Kim peered out through the open door and took in the landscape as it stretched to meet the horizon.In the next moment, she was dropping from 10,000 feet, reminding her senses: You are alive.Kimcouldnt help but smile. She had made a habit of seeking these reminders throughout her 64 years on Earth. Now, as she neared the end of her life, the message seemed to come through with renewed clarity as her wish to fly through the atmosphere one last time came true, thanks toher VITAS hospice team.It takes a lot of coordination, but when you have a whole team coming together, you can make anything work, says Daily, VITAS volunteer services manager.ToKim, cirrhosis of the liver seemed at first like a challenge waiting to be overcome. But after receiving a terminal prognosis and beginning care with VITAS,shestarted to focus on what she could feasibly achieve in the time that remained.Id been seeing Kim for about eight months, and one day she mentioned that shed been skydiving in the past and wanted to do it one last time, says Tammy,Kimsnurse.Dailysuggested that virtual reality (VR) could offer a simulated version ofKimsdesiredexperience without the risks associated with jumping from a plane. The VITAS team manager and physician agreed.On the day of the skydive, Kim was joined by the hospice team at her house. One of her nurses stood ready with the fan asKimsat down and donned an Oculus Rift VR headset.At one point,Kimstood from her chair, ecstatic with the sheer sensation of it all. After landing safely on the ground, she immediately began showering the team with appreciation.ForKim, the experience was clearly a dream come true, but not quite a replacement for the real deal:Tammysays that her patient still jokes about skydivingand bringing her favorite nurse along for the ride.Rikki Muro is general manager for VITAS Healthcare in Chicago. For more information about end-of-life care options, call VITAS Healthcare at 866.759.6695 or visit VITAS.com.

By Bob Johnson, RN, general manager for VITAS Healthcare in Collier County, for more information CLICK HERE!Anyone who has ever witnessed the agitated and nervous behavior of a patient with dementia or Alzheimers, or seen nursing home residents in wheelchairs seemingly staring into space for hours on end:Meet twiddle muffsand meet 65-year-old Wanda, aVITAS Healthcare volunteerwho makes them.The twiddle muff does exactly what its odd name implies: Its a glove-like sleeve for the hands,similar toold-fashioned hand-warming muffs. Each colorful muff features crocheted-in knots and bunches of yarn that encourage patients to keep their hands and minds occupied by twiddling away with the muffs sensory, whimsical features.These twiddle muffs have tactile elements that keep our patients constantly engaged, saysthe VITAS business manager who discovered them while visiting alocalchurchs knitting-crocheting group. The first day I encountered them, I took them straight to my team, telling them how phenomenal they would be for all of ourmemory care patients.Something to Make Them a Little HappierT average twiddle mufftakes about 12 hours to create, according to Wanda, andis about the size of an oversized glove that fits over a patients hand. A variety of textures encourage touching, feeling, andtwiddling,such as a string of different-sized knots, long thick appendages, or tightly packed balls or bumps.Wandas volunteer craftsgroupdonatesblankets,afghans, hats, mittens, and a variety of comfort itemsto VITAS patients and seniors in other healthcare settings.I really wanted to make the twiddle muffs to give patients and nursing home residents something to do, something to keep them busy and maybe make them a little happier, Wanda says. I try to make anything they can play with.Engaging, Tactile, and UtilitarianSimilar creativity is at work at the Veterans Affairs Medical Centerwhere VITAS donated 10 volunteer-sewn fidget blankets forveteran patients.The quiltsfeature interactive elementszippers, beads, buttons, pockets, neckties,watches,and shoestringsto encourage attention and manipulation.The blankets are wonderful tools for veterans struggling with dementia and neurological symptoms.So Many People You Can Help...Wanda, who learned to crochet at age 12 from her grandmother, isthrilled that her creative pastime brings joy to others.There are so many places and so many people you can help, she says.

Pets often bring out an added level of joy in certain people with an emotional and physical bene?t that is invaluable.Seniors who are pet owners enjoy less isolation and loneliness, are typically more active, weigh less and visit doctors less frequently than non-owners. Pet ownership has also been linked to lower blood pressure, higher levels of relaxation hormones and stronger immune systems.Everybody Benefits The positive effects of bonding benefit the animals, too, through increased opportunities for socialization and better health. Even military veterans returning home from duty have been found to benefit by working with shelter dogs to provide obedience training. VITAS Healthcare has offered a Paw Pals program for several decades. Usually that pet is a dog, but other animals, including cats, birds, snakes and miniature ponies, have joined the VITAS volunteer ranks as pet companions.Well Screened, High-Impact PetsPaw Pals are not necessarily therapy dogs. They are considered friendly visitors. Because hospice care is, above all, comfort care, VITAS volunteer managers screen potential animals and provide volunteer training to owners. Paw Pals volunteers and their pets who are accepted visit nursing homes, assisted living facilities and private homes on a regular basis.How to Visit a Hospice Patient Ideal Paw Pal pets have no expectations and arent looking for anything. If the patient wants to talk, they want to listen. If the patient wants to pet them, they relax and enjoy it. In return, they bring the ultimate comfort care to a patient near the end of life. They bring back memories and encourage laughter. They boost activity and offer unconditional love. Even in patients who are no longer able to speak or carry on a conversation, VITAS Paw Pals elicit smiles and emotions that seem to arise from long-lost places and times. If you or someone you know is interested in being a Paw Pal volunteer, or any of the many other kinds of volunteers VITAS relies on, contact volunteer services manager Joanna Voorhees at 708.781.4401.Editors Note:Article Submitted by: By Cathy Carlson, VITAS Healthcare General Manager For more information about hospice care or end-of-life care options, call VITAS Healthcare at 866.759.6695 or visit VITAS.com.

By Dr. Valerie Hart Quezada, Team Physician/Geriatrician, VITAS HealthcareIf we believe in stereotypes, older adults are all the same. Yet this fast-growing population is very complex and diverse. They defy a simple description because chronological age is not the same as physiologic age.Both Sylvester Stallone and Arnold Schwarzenegger are in their late seventies while living robust, active and independent lives. Contrast this with a frail individual of the same age living in a nursing home with balance and mobility issues who relies on support for daily living activities.Approaching the Older PatientBecause we age in different ways, its important to know as much as possible about the patient we are treating and cultivate skills to match care to their health, functional status, priorities, and life expectancy. It is not enough to know age and comorbidities only.The baby boomer population is living longer yet doing so with chronic illnesses. Often, health professionals are not well prepared to care for patients with multiple chronic conditions and have a harder time understanding disease trajectories. The silver tsunami of 73 million individuals in the US will require the mindfulness and holistic care of clinicians.Physiologic vs. Chronological AgeThe normal aging process produces an increase in hearing and vision issues, frailty, sleep disturbances, urinary tract infections (UTIs), potential falls, gait and balance issues, and osteoporosis.How the body manages these changes will depend more on physiologic age than chronological age.Chronological age is the number of years, months, days since birth.Physiologic age is the patients functional age based on their lifestyle, diet, exercise or fitness level, and even education.When aging, cellular and molecular damage contribute to a decrease in physiologic reserve, or the bodys ability to withstand stress and recover from illness. The loss of muscle mass, increase in cortisol, and changes in hormones and blood pressure can affect homeostasis. With decreased physiologic reserve, small insults can result in significant decline. A new medication can lead to acute renal failure. Contracting pneumonia can turn into respiratory failure. A minor illness or even dehydration can produce delirium.Suppose an 85-year-old who is robust, independent, and perhaps still driving gets a UTI. They may experience a dip in functionality but can likely recover quickly. Another 85-year-old who is weaker and frail may also acquire a UTIand may not be able to recover to baseline.Applying the 4Ms to Determine Health Status and GoalsDeveloped by the Institute for Healthcare Improvement, the 4Ms help healthcare professionals gauge the status of their patients. They are:Mentation, which is the patients presentation of dementia, delirium, or depression. What is their mental state? Do they have cognitive challenges or are their typical age-related responses?Mobility or their ability to get around. Do they use a cane or rollator? Do they need to? Older adults value being independent, so we need to identify when they start to become frailer and find ways to address barriers to being more active.Medications: Review these and identify what does not belong and discontinue. Ensure they understand the medications they are taking. Also, can they manage their medications?What matters most? Asking this question will help you identify what their values and goals are. These may vary by cultural or religious affiliation, life experiences and diseases. Do they want to be more active? Spend more time with family? What will help them achieve what matters most to them?A fifth M can be multimorbidity if the patient is experiencing several chronic conditions.Open-Ended Questions: What HCPs Can AskRemember that most older adults do not want to become a burden to loved ones. When they express this to us, it is a good place to start the conversation. This is an ongoing discussion because it can change for the patient over time, as their serious illness progresses. Here is a sampling of questions:What do you think is going on with your health? This enables physicians to prognosticate.What do you think the healthcare system or I can do for you? Identifies the patients expectations.Is there something you want to do in the future? Or, what activities do you find enjoyable that may have been disrupted? Physical therapy may help them increase their abilities.Who is important in your life? How often do you see them? This can reveal social deficits and isolation.Are you able to care for yourself? They may not reveal deficiencies unless asked. Minor interventions can help.Once assessed, acting on these responses can help us align the care plan with what matters most to the older adult. If opting for hospice and palliative care, the patient receives wholistic care that includes medical, psychosocial, and spiritual support. Sharing information about the Medicare Hospice Benefit, which covers 100% of hospice services under Medicare Part A, can ease the patients mind about financing this type of end-of-life care.Respect: The Key to SensitivityOlder adults are experts on aging, and it helps to show them sincerity and empathy. Because they sometimes experience ageism from their community, the healthcare system, or even their own family, they may not receive the care they need.Breakdowns in care may happen when healthcare professionals assume all older adults are the same or focus only on the medical instead of the whole person. The cognitive/emotional, familial/social, environmental, and financial domains are interconnected. Taking this whole-hearted approach will help healthcare professionals provide care that enhances their quality of life.Do you have a patient with serious illness or multiple morbidities? Could it be time to have a goals of care conversation? For assistance with this conversation or questions about hospice-eligibility, contact VITAS.

When 18-year-old Abraham Maldonado confided in Chaplain Antonio Rivera-Maldonado (no relation) that he wanted to attend his high school graduation ceremony, Antonio immediately shared that wish with the rest of Abrahams hospice team.Abraham, a VITAS patient in Orlando, Florida, has lived with malignant neoplasm (a cancerous tumor) of the spinal cord for a decade and may only have another six months to live. Despite battling his illness, he has continued attending high school through a virtual learning program at home.Only a few credits shy of completion, Abraham wanted to attend his graduation and celebrate his accomplishment.The moment Team Manager Nicolette Burton heard about her patients final wish, she agreed: They had to make it happen.Abraham doesnt like to complaineven when hes in pain, Nicolette says. Despite everything hes been going through, he has such an outgoing, positive, can-do attitude. I wanted to do anything I could to help make his dream come true.A Dream RealizedThanks to Antonios work, Abraham was granted his wish. A private ceremony was held in the Boone High School auditorium in Orlando. With his family, high school friends, VITAS interdisciplinary team, and Boone High School staff in attendance, Abraham received his honorary high school diploma.It feels good to know that I could make a difference in his life.-Werner Ferman, VITAS LPNOriginally from Puerto Rico, Abrahams family has made many sacrifices to ensure he receives the best care possible.[He] is a gift. With support and love, his family rallies around him, Social Worker Lisa Camacho says. Theyve never once made him feel like hes a burden. They love him. His condition is only a part of who he is. Theyre running alongside him with comfort and support as he continues his unique journey on Earth.Finding the Strength to PersevereAbraham worked hard to achieve his goal, and it was far from easy. The daily hurdles and obstacles were challenging.At one point, as much as he loved learning, it was becoming difficult to find the strength to continue.Abraham was frustrated and did not want to go back to school. He almost gave up. says Antonio. So, his father made a deal with him. If he went back to school and finished, his [dad] would go back to school, and they would graduate together.Today, Abraham is a high school graduate. And on July 10, he attended his dads graduation ceremony for a bachelor of science degree in mechanical engineering.It was great to be there for Abraham on his special day, says Werner Ferman, a licensed practical nurse on Abrahams team. Hes a warrior and a champion! I dressed up as the VITAS mascot and cheered him on as he received his diploma. It feels good to know that I could make a difference in his life, providing care that enabled him to achieve his goal and dream.Despite numerous struggles, 18 surgeries, and years of chemotherapy and radiation treatments, Abrahams personal life quote is, Never give up! says Nicolette.Abraham and his family celebrated his dads college graduation just a few weeks after Abrahams high school graduation ceremony.