By Sherika Newman, DO, Associate Medical Director, VITAS Healthcare
As clinicians, we know from personal experience and surveys that patients who are facing the challenges of advanced illness want to talk about their preferences and goals for care, and their clinical teams want to talk about the same issues, too.
But too often, no one knows how to start the conversation.
That’s where nurses play key roles, especially for patients with advanced heart disease and cancer, the two leading causes of death in the US in 20211 and the top-ranked causes of US hospice admissions.
Understanding Patient Goals
In 2018, the most recent year for National Hospice and Palliative Care Organization statistics, cancer caused 29.6% of all hospice admissions and 336,307 deaths, while heart disease caused 17.4% of all hospice admissions and 196,971 deaths.2
Effective care plans for heart disease and cancer are individualized, based on each patient’s goals, values, and preferences. Nurses are in the ideal position to explore and understand those values because they spend so much time with patients and their families.
Through nurses' regular and consistent visits and checks, develop a special level of rapport that’s unique in the clinical team.
Nurses listen to and engage in patients’ bedside or living-room conversations. They stay behind after the physicians and specialists leave to make sure patients understand what they’ve just been told. They hold patients’ hands, care for them, calm their fears, and help them explore options for care as their illness progresses.
‘Whole-Person’ Viewpoint: Questions to Consider
Nurses play a pivotal role on each clinical team to:
- Explore what patients and family truly understand about their options, their diagnosis, and their prognosis
- Plant the seeds for (or engage in) goals-of-care conversations to ensure that each patient’s goals, values, and preferences for care are discussed, decided, and updated
- Assess whether a patient’s goals are realistic
Clinical teams should consider a “whole-person” view of each patient to determine the next phases of treatment. Beyond labs and test results, nurses who have regular contact and interactions with patients and their families should raise additional questions to help determine when comfort care is the next option:
- Has the patient been hospitalized/readmitted multiple times in the 6-12 months?
- Is the patient spending more and more time in bed, in a chair, or in the same room?
- Is the patient experiencing constant nausea, shortness of breath, or fatigue?
- Is the patient experiencing heightened anxiety, agitation, or delirium?
Hospice should be considered when patients show ongoing signs of decline, when decisions must be made about continuing or stopping aggressive treatments, and when patients or their surrogates decide that the side effects of ongoing treatments are no longer tolerable or preferred.
Hospice Eligibility Indicators
Indications of hospice eligibility for advanced heart disease include:
- Symptoms: shortness of breath, palpitations, angina, anxiety, nausea/vomiting, and agitation
- Clinical eligibility guidelines: NHYA Class III or IV heart disease if dyspnea, fatigue, palpitations, or angina are present with minimal exertion or at rest; no further surgical/treatment options exist
- Available VITAS modalities to provide comfort-focused, high-acuity hospice care: continuation of cardiac medications, inotropes, intravenous and subcutaneous diuretics, respiratory therapy, implantable cardioverter defibrillators (ICD), and left ventricular assist devices (LVAD)
Indications of hospice eligibility for advanced cancer include:
- Symptoms: pain, nausea/vomiting, anxiety/agitation/restlessness, dyspnea
- Clinical eligibility guidelines: Eastern Cooperative Oncology Group (ECOG) score of 2 or greater; Palliative Performance Scale (PPS) score of 70% or lower
- Available VITAS modalities to provide comfort-focused, high-acuity hospice care: IV hydration, total parenteral nutrition, thoracentesis/paracentesis, blood transfusions, PleurX drains, parenteral opioids, venting G tube
Patients Can Be Home with Hospice Care
Compassionate VITAS hospice care offers tangible benefits to patients and their families:
- Comfort-focused symptom management for the patient and psychosocial support for their families from a seven-member hospice team
- Care usually provided in the patient’s preferred setting: home, nursing home, or assisted living community
- Individualized care plans based on each patient’s values, goals, and preferences for care near the end of life
- Reduced hospitalization and care interruptions near the end of life
- One study of terminally ill residents in nursing homes shows that residents enrolled in hospice are much less likely to be hospitalized in the final 30 days of life than those not enrolled in hospice (24% vs. 44%)3
1US Centers for Disease Control & Prevention. Leading Causes of Death. Retrieved from Fast Facts: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
2National Hospice and Palliative Care Organization. (2020). Hospice Facts & Figures. Retrieved from: https://www.nhpco.org/factsfigures/
3Miller, S., Gozalo, P., & Mor, V. (2011). Hospice enrollment and hospitalization of dying nursing home patients. American Journal of Medicine, 111(1):38-44.