VITAS Advantage: Case Study on Complex Modalities for Long-Term Care Facilities
VITAS Case Study: Patient with Advanced Leukemia
TS*, an 80-year-old nursing home resident with advanced leukemia, develops severe fatigue secondary to anemia. TS’ elderly wife is no longer able to care for him at home.
Based on a consultation between TS’ oncologist, his wife, and the facility’s medical director, TS is sent to the local hospital as a non-admitted patient for a blood transfusion and returned to his nursing home later that day, still on hospice care.
His care plan includes regular visits from a hospice team and bedside comfort care through oxygen/respiratory therapy and multi-modal pain management. Hospice teams supplement care provided by the facility and educate staff members on end-of-life care.
TS spends the final four weeks of life on hospice care in his nursing home, where he dies peacefully with his wife and adult children at his bedside.
*These initials represent an anonymized patient and are used for the purposes of education only.
Hospice Use Increases Among Leukemia Patients, Improving Quality of Life
A growing proportion of Medicare beneficiaries with leukemia—including those living in long-term care facilities—were enrolled in hospice during the previous decade and were found to be markedly less likely to die in the hospital or receive chemotherapy near death compared with non-hospice leukemia patients.
Data shows that hospice care improved leukemia patients’ quality of life and reduced the likelihood of in-hospital death, yet only about half of eligible patients in this population use hospice services. Moreover, hospice lengths of stay remained short, especially among the one-fifth of patients dependent on blood transfusions, according to a 2017 study presented to the American Society of Hematology (ASH) and published in Blood, its journal.
“While hospice use in leukemias appears to be increasing, patients with blood cancers use palliative and hospice services at end of life less frequently than those with solid tumors,” write the authors. “Markedly shorter time on hospice among transfusion-dependent patients indicates that the need for transfusion support may significantly delay hospice enrollment.”
Using the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database, investigators analyzed data on 21,076 beneficiaries with acute or chronic leukemia (median age, 79 years; women, 44%; acute leukemia, 46%) who died between 2001 and 2010. Transfusion-dependence was defined as receiving two or more transfusions at least five days apart within 30 days prior to death or hospice enrollment.
Among all leukemia patients:
- Hospice use increased from 35% to 49% from 2001 to 2011 (P < .0001).
- However, median length of hospice stay was only 9 days.
- Inpatient deaths decreased (from 51% to 38%), as did the receipt of chemotherapy within 14 days of death (from 15% to 10%).
- 20% of leukemia patients were transfusion-dependent.
Hospice care was found to improve the quality of the patient’s end-of-life experience. Leukemia patients who received hospice services had dramatically improved performance scores on quality end-of-life care measures compared with those who do not receive hospice care.
Leukemia patients in hospice had:
- A dramatically lower likelihood of death in the hospital (3% vs 75%)
- Less likelihood of receipt of chemotherapy in the last 14 days of life (5% vs 16%)
- A lower rate of end-of-life Medicare spending ($7662 vs $17,783)
Although transfusion-dependent patients had a slightly higher likelihood of hospice enrollment, they also had a 51% shorter time in hospice and a 38% higher risk of receiving hospice services for less than three days.
“These findings suggest that patients are having to choose between getting the transfusions they need and getting high-quality end-of-life care,” the authors write.
Thus, while more leukemia patients are receiving hospice care, albeit very late, those who need palliative blood transfusions are receiving this quality care even closer to death, preventing the hospice multidisciplinary team from the time needed to provide the full array of palliative and supportive end-of-life services, note the authors. They advocate for a change in Medicare policy regarding the provision of palliative transfusions.
The VITAS Advantage Provides Complex Modalities to Residents With Advanced Illness
VITAS-provided modalities include
- Multi-modal pain management
- Artificial fluid and nutrition
- Oxygen, including high-flow O2
- BiPAP / CPAP
- Ventilator removal support
- Blood transfusion TPN lyte
- IV fluids
- PleurX drains
- Venting G tube
- Nutritional counseling
- Proactive wound management
For long-term care professionals, hospice care in facilities:
- Ensures that the care residents receive comfort-focused care for advanced illness in their preferred setting
- Relieves burdens and stress on LTC staff by incorporating complex modalities to address pain, manage symptoms and fluids, provide wound care, and offer comfort-focused treatments for advanced illnesses, including cancer, heart disease, lung disease, Alzheimer’s/dementia, sepsis/post-sepsis syndrome, and more
- Reduces readmissions of LTC residents to the hospital or emergency department and improves overall metrics for long- and short-stay quality of care, and patient/family satisfaction.
Source: Olszewski, A. & Egan, P. (2017) Transfusion Dependence and Use of Hospice Among Medicare Beneficiaries with Leukemia. Blood, 130(Suppl 1): Abstract 277