This interactive Michigan Physician Ebook contains 9 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Michigan Continuing Medical Education
MICHIGAN MEDICAL LICENSURE PROGRAM
MANDATORY CME REQUIRED FOR MICHIGAN LICENSE RENEWAL MD & DO: • 3 CREDITS IMPLICIT BIAS (NEW) • 8 CREDITS DEA REQUIREMENT (NEW) • 3 CREDITS PAIN & SYMPTOM MANAGEMENT • 1 CREDIT MEDICAL ETHICS
INCLUDES: DEA’s New One-time MATE Requirement
InforMed is Accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™ MIPS MOC STATE LICENSURE
CME DEADLINE: PRIOR TO YOUR UPCOMING LICENSE RENEWAL
AVAILABLE ONLINE AT: MI.CME.EDU
MICHIGAN PHYSICIAN
Dear Colleagues, Effective June 27, 2023, renewing DEA-registered practitioners must complete eight (8) hours of one-time training on the treatment and management of patients with opioid or substance use disorders. Beginning June 1, 2022 all Michigan physicians (MD/DO) must complete implicit bias training as a condition of license renewal. The new requirement can only be completed via live or online interactive methods. For initial renewal after June 1, 2021, licensees will only need to have one (1) hour for each year since the rule’s promulgation date of June 1, 2021. For all subsequent renewals, licensees and registrants are required to complete one (1) hour of implicit bias training for each year of their license or registration cycle. Additionally, as a prerequisite for license renewal, physicians must complete at least three (3) credit hours of continuing medical education on the topic of pain and symptom management, and at least one (1) credit hour on medical ethics.
Scan the QR code to complete your Implicit Bias Requirement!
The InforMed Michigan Medical Licensure Program is designed to streamline the education requirements of the Michigan Board of Medicine. Licensees who complete this program optimize their learning path while satisfying professional credentialing requirements for the new implicit bias training, three (3) credit hours in pain and symptom management, one (1) credit hour on medical ethics and eight (8) hours on the DEA’s new one-time MATE Requirement. To complete the program online, visit BOOK.CME.EDU , enter the book code MI24CMEB in the box then click GO . Thank you for choosing lnforMed as your CME provider. We strive to create a high quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards, The lnforMed CME Team
LARA - Bureau of Professional Licensing | P: (517) 241-0199 | F: (517) 241-0032 Department of Licensing and Regulatory Affairs | Bureau of Professional Licensing | PO Box 30670 | Lansing, MI 48909
We are a nationally accredited CME provider. For all board-related inquiries please contact:
1-800-237-6999
BOOK.CME.EDU
BOOK CODE: MI24CMEB
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What’s Inside
01
HOSPICE AND PALLIATIVE CARE FOR HEALTHCARE PROFESSIONALS COURSE ONE | 1 CREDIT SATISFIES THE MANDATORY CME REQUIREMENT ON MEDICAL ETHICS The purpose of this course is to provide healthcare professionals information on how to care for their dying patients. Hospice levels of care, regulations, ethical issues, and special populations are discussed. SUBSTANCE USE DISORDERS: A DEA REQUIREMENT COURSE TWO | 8 CREDITS SATISFIES THE MANDATORY CME REQUIREMENT ON PAIN AND SYMPTOM MANAGEMENT AND THE NEW ONE-TIME TRAINING REQUIREMENT IN OPIOIDS AND CONTROLLED SUBSTANCE AWARENESS AND THE DEA’S ONE-TIME MATE REQUIREMENT Physicians and Physician Assistants (PAs), care for patients with disorders in many healthcare settings. Individuals may seek care for an acute illness or worsening of a chronic condition. Often, pain is the leading reason for seeking medical care. Appropriate prescribing practices are critical for all medications, but controlled substances require special attention. The Drug Enforcement Agency (DEA), the Food and Drug Administration (FDA), and the U.S. Department of Health and Human Services (HHS) all have a role in controlled medication schedules. Prescribers must understand federal and state requirements for all controlled substances. This course will provide a general review of federal and state-controlled substance regulations and the prescribing practices for controlled substances. Additionally, substance use disorders are complex phenomena affecting many lives. This course also reviews common substance use disorders, including alcohol, anxiolytics, stimulants, hallucinogens, and tobacco/vaping. However, the focus is on clinical safety considerations when prescribing non-cancer-related opioid medications for acute/chronic pain in adults. LEARNER RECORDS: ANSWER SHEET & EVALUATION REQUIRED TO RECEIVE CREDIT
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We offer a convenient package designed to meet your Mandatory CME Requirements ( Including Implicit Bias Requirement)
Mandatory CME Requirements Package ( including Implicit Bias Requirement)
InforMed offers a convenient package of courses to fulfill your Michigan CME requirements, including all your mandatory subjects. Scan the QR code to review and purchase the online package that meet your mandatory CME requirements.
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Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs ABA American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0® MOC/MIPS CREDIT INFORMATION Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABOHNS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
ABIM
American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABOHNS American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC)
ABPath American Board of Pathology’s Continuing Certification Program
ABP
American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M 1 AMA PRA Category 1 Credit TM 8 AMA PRA Category 1 Credits TM
Activity Title
ABA
ABIM ABOHNS ABPath
ABP
1 Credit LL 8 Credits LL
1 Credit MK 8 Credits MK
1 Credit SA 8 Credits SA
1 Credit LL 8 Credits LL
1 Credit LL+SA 8 Credits LL+SA
Hospice and Palliative Care for Healthcare Professionals Substance Use Disorders: A DEA Requirement
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, PS = Patient Safety
Table 3. CME for MIPS Statement Completion of each accredited CME activity meets the expectations of an Accredited Safety or Quality Improvement Program (IA PSPA_28) for the Merit-based Incentive Payment Program (MIPS). Participation in this Clinical Practice Improvement Activity (CPIA) is optional for eligible providers. DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the self-assessment questions. To receive credit for your courses, you must provide your customer information and complete the man- datory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE FASTEST AND EASIEST! • Go to BOOK.CME.EDU and enter code MI24CMEB in the book code box, then click GO. • Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your self- assessment. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
Enter book code
MI24CMEB
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
BY MAIL Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options Price
Option
Code
Credits
ONLINE PACKAGE Hospice and Palliative Care For Healthcare Professionals Substance Use Disorders: A DEA Requirement Understanding, Recognizing and Mitigating Implicit Biases in Healthcare ENTIRE PROGRAM Hospice and Palliative Care For Healthcare Professionals Substance Use Disorders: A DEA Requirement
$110
12 Credits
$95
MI24CMEB
9 Credits
$80 Substance Use Disorders: A DEA Requirement $30 Hospice and Palliative Care for Healthcare Professionals
MI24CME-80 MI24CME-302
8 Credits
1-800-237-6999 1 Credit
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HOSPICE AND PALLIATIVE CARE FOR HEALTHCARE PROFESSIONALS
COURSE DATES:
MAXIMUM CREDITS: 1 AMA PRA Category 1 Credit ™
FORMAT:
Release Date: 2/8/2022 Exp. Date: 1/31/2028
Enduring Material (Self Study)
TARGET AUDIENCE This course is designed for all physicians and other healthcare professionals. COURSE OBJECTIVE The purpose of this course is to provide healthcare professionals information on how to care for their dying patients. Hospice levels of care, regulations, ethical issues, and special populations are discussed.
HOW TO RECEIVE CREDIT: ● Read the course materials. ● Complete the self-assessment questions at the end. A score of 70% is required. ● Return your customer information/
answer sheet, evaluation, and payment to InforMed by mail, phone, fax or complete online at BOOK.CME.EDU .
LEARNING OBJECTIVES Completion of this course will better enable the course participant to:
1. Describe the purpose of both hospice and palliative care, how they address life-limiting illness for the patient and family, and how they contribute to the improvement of quality of life of patients with life-limiting illness. 2. Identify the different levels of hospice care, services provided, and Medicare (CMS) eligibility requirements. 3. Identify misconceptions and barriers to providing hospice and palliative care. 4. Discuss professional and educational resources clinicians can provide to support patients and families coping with life-limiting illness as well as to support the healthcare professionals who are providing care in these situations. ACCREDITATION STATEMENT InforMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. IMPLICIT BIAS IN HEALTHCARE Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics. DESIGNATION STATEMENT InforMed designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit ™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Book Code: MI24CMEB
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FACULTY Russell Yoon, MD Emergency Medicine Department Cooper University Health Care Margaret Salinas, PhD, MS, APRN, FNP-C Lead APRN Planner and Editor Colibri Healthcare ACTIVITY PLANNER Michael Brooks CME Director InforMed DISCLOSURE OF INTEREST
COURSE SATISFIES 1 Medical Ethics
MICHIGAN SPECIAL DESIGNATION This course satisfies one (1) credit hour on medical ethics.
The Michigan Board of Medicine requires all physicians (MD/DO) to complete a minimum of one (1) hour on medical ethics.
In accordance with the ACCME Standards for Integrity and Independence in Accredited Continuing Education, InforMed implemented mechanisms, prior to the planning and implementation of this CME activity, to identify and resolve conflicts of interest for all individuals in a position to control content of this CME activity.
FACULTY/PLANNING COMMITTEE DISCLOSURE The following faculty and/or planning committee members have indicated they have no relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients: ● Russell Yoon, MD ● Margaret Salinas, PhD, MS, APRN, FNP-C ● Michael Brooks STAFF AND CONTENT REVIEWERS InforMed staff, input committee and all content validation reviewers involved with this activity have reported no relevant financial relationships with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. DISCLAIMER *2024. All rights reserved. These materials, except those in the public domain, may not be reproduced without permission from InforMed. This publication is designed to provide general information prepared by professionals in regard to the subject matter covered. It is provided with the understanding that InforMed, Inc is not engaged in rendering legal, medical or other professional services. Although prepared by professionals, this publication should not be utilized as a substitute for professional services in specific situations. If legal advice, medical advice or other expert assistance is required, the service of a professional should be sought.
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Book Code: MI24CMEB
INTRODUCTION
Palliative care likely originated in Roman times, as members of the community wore a protective cloak named “pallium.” Today, palliative care is defined as the protection from and prevention of suffering via identification, assessment, and treatment of physical, psychosocial, and spiritual problems. 1 Palliative care is the overarching, supportive approach that helps seriously ill patients and families address problems and improve their quality of life. 2 Hospice is a type of palliative care, specifically for those that have a terminal disease and life-limiting prognosis. Hospice What is palliative care? Palliative care is the treatment of the discomfort, symptoms, and stress associated with advanced or life-limiting illness. 3 The emphasis of palliative care, which occurs across the patient’s illness trajectory, is on (1) encouraging conversations about goals of care at time of patient diagnosis of a serious illness; (2) considering the benefits versus burdens of treatment options; and (3) attending to the physical, psychological, social, spiritual, and existential needs of the patient/family unit across the lifespan. Patients receiving palliative care often suffer from the symptoms and stress of serious illnesses, including but not limited to cancer, dementia, heart failure, Parkinson’s disease, and chronic obstructive pulmonary disease. 4 Palliative care teams offer this care to support curative or other treatment plans of care and help patients and families understand their choices for medical treatment. 2 Palliative care is not dependent on prognosis and patients do not need to be in hospice or at end of life (EOL); patients can receive palliative care at any age and at any time during their illness. 3
and palliative care can improve a patient’s quality of life by: ● Providing relief from pain and other distressing symptoms such as nausea and fatigue; ● Integrating emotional, psychological, and spiritual aspects of patient care; ● Offering a support system to enhance quality of life; and ● Offering bereavement and grief counseling to help the family cope during the patient’s illness and after death. of care; physical aspects of care; psychological and psychiatric aspects of care; social, spiritual, religious, and existential aspects of care; care of the patient near EOL; and ethical and legal aspects of care. 5 When providing palliative care, healthcare professionals should consider the population of the person for whom they are caring to provide the best and most appropriate care. Different populations may include adult, pediatric, neonatal, perinatal, and geriatric patients. Besides physical needs, other issues faced by seriously ill patients may include the following: 6 ● Losing independence. ● Maintaining self-determination and a sense of control. The eight domains of palliative care to meet the needs of the whole person are structure and process ● Decision making about how and where to die. ● Declining functions and related concerns about being a burden. ● Fear of pain and other distressing symptoms.
Case study 1 Instructions: Please read through the case study below and consider the questions that follow. You are seeing a new patient in the office, Ms. Johnson, as her previous primary physician has recently retired. Ms. Johnson is 80 years old and has a history of well-controlled hypertension and hypercholesterolemia, as well chronic obstructive pulmonary disease (COPD). Despite progressively worsening pulmonary disease and multiple attempts at quitting, Ms. Johnson continues to smoke cigarettes, but she has cut down from 1 pack to a half pack per day. In addition to her pulmonary inhalers, she uses home oxygen at 2 L per minute on an as- needed basis. Ms. Johnson’s son, Raymond, reports that her activities of daily living are now noticeably limited by shortness of breath. He asks if there are any services that could provide additional support to his mother. You suggest that it may be a good time to consider palliative care services. Ronald is quite surprised by the suggestion and becomes concerned that you are “giving up” on his mother, probably because she is still smoking. You go on to explain the emphasis of palliative care is supportive, that it may continue for an extended period of time, and that it is not the same as hospice care. Questions 1. All of the following describe palliative care programs EXCEPT: a. The patient must have a life expectancy less than 6 months. b. Risks, benefits, and goals are considered when considering treatment options. c. Palliative care is intended to limit and prevent suffering. d. Families may also participate in the program. Explanation : Palliative care may be utilized for extended periods of time in treating advanced illnesses. Hospice care, which is a subset of palliative care, is typically utilized during the last months of life, and requires a life expectancy less than 6 months. Questions continued on next page ►
Book Code: MI24CMEB
Page 3
Questions 2. Based on the provided information, palliative care is MOST APPROPRIATE for which patient in the following list?
a. A 32-year-old female diagnosed with pre-diabetes. b. A 72-year-old male with a diagnosis of dementia.
c. A 75-year-old female who recently underwent knee replacement surgery. d. A 65-year-old male with recent resection of a superficial basal cell carcinoma.
Explanation : The patient with dementia has a diagnosis of a disorder that is chronic and progressive. He and his family are most likely to benefit from palliative care at this time. Pre-diabetes may be reversed with lifestyle changes, and it is not necessarily a progressive and chronic disorder.
What is hospice care? A subset of palliative care, hospice care is for individuals who are facing a serious or life-limiting illness of six (6) months or less and is provided by an interdisciplinary team of clinicians. This team provides pain management and emotional and spiritual support that is expressly tailored to the patient’s needs and wishes at the end of life. Hospice care does not end with the patient’s death; bereavement and grief support continue for the family for up to 13 months. 7 Incidence of care and distribution of hospice service To be eligible for hospice, two physicians (including the medical director of the hospice agency) must agree on a patient’s terminal diagnosis. 7 Cancer remains the most common hospice primary diagnosis, while the most common noncancer primary diagnoses are heart and circulatory disorders, followed by dementia. Despite growth in the use of hospice services across all disease groups, 8 racial disparities remain. Population-based cohort data linked to Medicare claims, show that Black patients are more likely to receive intensive therapy in the last 6 months of life and less likely to receive hospice care than White patients. 9 Disparities in access to care, distrust in the healthcare system and advanced care planning, economic factors, faith beliefs, preferred place of death, and overestimation by physicians of time remaining have all been associated with lower hospice and palliative care use in non-White patients. 10 Hospice and palliative care organizations and healthcare professionals can help ensure access and awareness to high-quality care by providing educational programs and outreach and by meeting the cultural and language needs of various groups within their community. Length of stay The median length of stay (LOS) for Medicare patients receiving hospice care was 18 days, and more than 25% of decedents enrolled in hospice during the last week of life. 7,11 Despite having 6 months of eligibility on the Medicare Hospice Benefit, most patients receive care for a few days to a few weeks. Research has shown that a longer LOS benefits patient care, therefore the short median LOS deprives patients and families of support and education needed at the end of life 11 . There are multiple factors contributing to these short stays and late referral to either palliative care or hospice.
Two of these factors are: ● Physician/provider reluctancy or discomfort with EOL conversations until death is imminent, and ● Patients’ or families’ lack of acceptance of a terminal prognosis. 12 Physician/provider reluctance Barriers affecting timely referrals to hospice care by physicians or other providers include uncertainty of prognosis, ignorance regarding the criteria for admission to hospice services, and discomfort in discussing the prognosis with the patient and family. 13 More specifically, providers find it hard to estimate when a patient has met the criteria of 6 months or less expected time left. 13 In addition, many healthcare providers have difficulty speaking about EOL. According to, 14 there is an aspect of avoidance and emotional stress among physicians: “One physician stated, "Sometimes I can get very close to people, and I don’t want to do it, too, so sometimes it’s my own personal barrier.’” 14 Because of this delay, oftentimes the patient is imminently or actively dying when the physician or other healthcare provider makes the decision to approach the family. Patients’ or families’ lack of acceptance Many hospice clinical teams point out that families are misinformed about what hospice care is and that it makes them feel as if they are giving up on their loved one. 14 The most common misconception was that a person can only go to hospice when they are imminently dying. 14 In one study that looked at barriers to hospice care, participants commented on both the beneficial and potentially detrimental beliefs, including how families can find comfort at EOL; however, sometimes the hope of a miracle “could lead to prolonged suffering because of nonmedically indicated life-sustaining measures. 14 In addition, patients and families are often unclear about the differences between palliative care services and hospice. 12 Barriers further emphasize the need for clinicians to educate themselves on the benefits of early palliative care and hospice referrals, as these services have been proven to improve quality of life, patient outcomes and goals, and reduce costs. 15 As the population ages, life expectancy increases, and the prevalence of advanced illness rises. Clinicians must be ready to introduce hospice and palliative care services early in a patient’s serious illness trajectory and not in the last days of a patient’s life.
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Book Code: MI24CMEB
○ Minor comfort care procedures, such as paracentesis, i.e., removing fluid from the abdominal cavity. 21 Volunteer services Hospice volunteers are used in day-to-day administrative and/or direct patient-care roles. Volunteers are an essential part of the interdisciplinary team and endure rigorous training to participate in hospice programs. Their role is to assist in various tasks, including caregiver support, patient companionship, legacy writing, and administrative duties. Bereavement services As indicated previously, both hospice and palliative care programs offer support to bereaved family members as they anticipate the patient’s death. However, hospice programs that are Medicare certified are required to also offer bereavement care to the family for 13 months after the death. These bereavement services may include monthly phone calls to the family members, acknowledgements of anniversaries, receptions honoring those on hospice services, and resources for support groups. 22 Hospice medicare benefit Sources of payment for hospice care include private health insurance, veteran’s benefits, the patient’s own income or family support, charitable donations, Medicaid, or Medicare. Medicare patients have a specific Hospice Medicare Benefit (HMB) that reimburses the hospice on a per diem basis. The hospice provides clinical support from the interdisciplinary team, as well as durable medical equipment and coverage of medications associated with the terminal illness. Approximately 85 percent of hospice reimbursement/payment comes from the HMB. 20 The HMB does not cover curative treatments or medications, care from specialists not approved by the hospice provider, or room and board for hospice care provided in a patient’s home or another facility, such as a nursing home. 20 These strict limitations contribute to provider hesitancy in referring patients to hospice. 12 In addition, hospice items and services under the HMB require that items and services be provided by Medicare- approved hospice programs made up of an interdisciplinary team, including members of specific disciplines. These team members, representing specific interdisciplinary team to provide suggestions and collaborate with the patient, family, attending physician, and hospice team. ● Nurses coordinate patients’ care and assess and manage symptoms. They provide patient and family education, collaborate with the physician and other team members, initiate and administer treatments, provide physical care, and offer emotional support. ● Home health aides are certified Nurses Assistants who provide personal care, support, and light housekeeping for the patient and family. disciplines, fulfill different functions 20 : ● The medical director works with the
Universal ethical principles apply in situations of referral to palliative care and hospice. Advanced directives and shared decision-making support patient autonomy. Beneficence and non-maleficence guide many of the decision points in palliative and hospice care where the focus is on relieving suffering and promoting quality of life. 16 Patients can be referred to hospice while remaining full code, leading to ethical concerns about balancing patient autonomy and avoiding harm. 17 End-of-life decision-making can be especially difficult and ethically challenging for patients with dementia. While decision aids are available to help caregivers make decisions, more research is needed to further develop these tools for use in different ethnic populations. 18 However, while the conversations can be very difficult, the ethical principle of fidelity calls for clinicians to be clear, There are four levels of hospice care, defined by Medicare, which correspond to both acuity level and payment structure: Routine home care, continuous (aka crisis) home care, respite care, and general inpatient care. 19 1. Routine home care : The level of care that most patients could receive at home. This level of care consists of interdisciplinary care delivered on an intermittent basis at the patient’s home, and it may include skilled nursing facilities (SNFs), group homes, and assisted living facilities. 20 2. Continuous home care : Used when patients have symptom management needs that require temporary 24-hour support. 20 This level of care, also known as crisis care, assists patients who may require a higher level of nursing care but desire to stay at home. 20 3. Respite care : Caregivers are allowed a period of rest while patients are cared for by an interdisciplinary team in a facility. In respite care, patients are allowed 5 days of care while on direct, and truthful about prognosis. 16 Levels of hospice care and services hospice services. Respites are pre-planned stays in facilities (e.g., inpatient units or SNFs) which can occur under the following circumstances: ○ Caregivers who may be suffering from physical or emotional exhaustion from taking care of a patient around the clock. ○ Caregivers who would like to attend a family event such as a graduation, wedding, or funeral. ○ Caregivers who become ill and cannot take care of the patient. 20 ● General inpatient care : When the patient develops uncontrolled acute symptoms or a medical issue which cannot be resolved in the home or with continuous care, general inpatient care must be provided by the hospice. These acute symptoms include issues such as: ○ Uncontrolled pain and/or agitation; ○ Uncontrolled seizures; ○ Uncontrolled nausea and vomiting; ○ Unmanageable dyspnea, i.e., shortness of breath; ○ Complex wound care; and/or
Book Code: MI24CMEB
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● Social workers evaluate and support caregiving resources, seek out community resources, assist patients and families with any legal or insurance concerns, and offer supportive counseling. ● Chaplains or pastoral counselors offer spiritual support to patients and family members, directed by the patient and family members’ needs, values, and beliefs. ● Bereavement counselors facilitate support groups, train bereavement volunteers, and design and distribute bereavement material to families.
Following the patient’s death, bereavement support is made available to caregivers, families, and friends for 13 months. ● Volunteer coordinators administer and develop the volunteer programs for each hospice. The coordinators recruit, train, and assign volunteers to hospice patients. ● Other members of the hospice team can include counselors, physical and occupational therapists, speech-language pathologists, homemakers, and volunteers.
Case study 2 Instructions: Please read through the case study below and consider the questions that follow. You are talking to your clinical colleagues about end-of-life care for a patient. Someone states that hospice is the same as palliative care and that only private insurance pays for hospice care. 1. You know this statement is not accurate, and you clarify to your colleagues that: a. Hospice is a subset of palliative care. b. Hospice is a subset of palliative care and can be paid for by private health insurance, veteran’s benefits, the patient’s own income or family support, charitable donations, Medicaid, or from the Medicare hospice benefit. c. Hospice can only be paid for by private health insurance. d. Palliative care is the same hospice care but for those in a hospital setting. Explanation : Hospice and palliative care are not the same. Palliative care is the overarching care of those with serous or advanced illness, in which hospice is a subset. Hospice is not only paid for by private insurance. Other sources of payment for hospice services are veteran’s benefits, self-pay, charity, Medicaid, or the Medicare Hospice Benefit. 2. Any patient can qualify for hospice care as long as they have all of the following EXCEPT: a. An advanced illness. b. Certification of terminal illness by a physician. Explanation : Only patients who have been diagnosed with an advanced or life-limiting illness and determined by a physician to have 6 months or less to live can qualify for hospice care. Having a family is not part of the hospice certification process. POPULATION SPECIFIC PALLIATIVE CARE Pediatric palliative care c. A family to care for them. d. 6 months or less to live.
Pediatric palliative care is specialized medical care for children of any age that can be provided at any stage of a serious illness, along with treatment meant to cure. 23 Pediatric palliative care, similar to that for the adult population, also aims to meet the emotional, developmental, and spiritual needs of patients and Perinatal and neonatal palliative care The Centers for Disease Control and Prevention 25 reports that births before 37 weeks gestation rose for the fifth straight year to 10.23% in 2019. This fact highlights the need for clinicians who can provide support and comfort to parents when their baby has a life-limiting illness or is born premature or stillborn. Geriatric palliative care Palliative care in the geriatric population is a collaborative and interdisciplinary approach focused on improving and maintaining quality of life for the patient’s remaining time. Patients with a primary diagnosis of cancer (32%) had the greatest number of days on palliative care, followed by primary diagnoses of circulatory/heart disease (13.2%) and pulmonary
their family members. 23 For example, psychosocial interventions can be offered to adolescents and young adults in the form of weekend retreats, transition services to help when they go back to school, sessions with social workers who provide counseling, and work with expressive arts therapists. 24 This specialized type of palliative care helps to guide the decision-making process to anticipate, prevent, and relieve suffering. Choices along the spectrum of this care include pregnancy termination (abortion) to full neonatal resuscitation and treatment. 26 disease (11.3%). 27 In addition to these diagnoses, dementia, including Alzheimer’s disease, vascular dementia, and dementia with Lewy Bodies, has been steadily increasing. 28 Regardless of etiology, pain is the most common complaint (50%) of palliative care patients. 28
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Book Code: MI24CMEB
FINDING MEANING
● Behavioral component : Conveying wishes to others and personally acting upon those wishes based on personal values. ● Spiritual component : Interpreting life’s purpose, unraveling its mystery, and leaving a legacy that helps explain it all. As individuals face dying, they may attempt to find meaning in their losses, their lives, their illness, and most importantly, in their own deaths by asking themselves what it means to be near the end of life, or by exploring what it means to no longer exist. 30 patient learns that death is imminent to the actual death, during which the patient oscillates between denial and acceptance of the prognosis. 34 Three clinical phases take place during the living-dying interval phase: acute, chronic, and terminal. As the patient moves through each of the phases, the dying process is determined by their feelings and reactions, which can continually change. 34 What this model can teach clinicians who work in palliative care and hospice care is to recognize how the varying changes emotionally affect the patient from the very first moment of learning of the terminal illness to the Doka describes another theory of life-limiting illness that includes the pre-diagnostic, acute, chronic, terminal, and recovery landmarks. 35 Each landmark then has an associated task of coping. In the pre- diagnostic landmark, individuals suspect an illness and seek out medical attention. 35 The acute landmark, initiated by the diagnosis, is when individuals attempt to understand the disease, maximize health, develop coping strategies, explore the effects of the diagnosis, express feelings, and integrate the present reality into their sense of past and future. 35 The chronic phase involves managing the symptoms and side effects while carrying out health regimens, normalizing life, maximizing social support, expressing feelings, and finding meaning in the suffering. 35 Doka’s model is based on the work of Ira Byock, who identified the importance of patients with a life- threatening disease attaining certain landmarks before death. 36 At each landmark, individuals have taskwork to complete. These landmarks include completing one’s affairs, resolving relationships, finding a sense of meaning in one’s life, experiencing love of self and others, acknowledging the finality of life and a sense of a new self, and letting go. Spirituality-based A patient’s spiritual perspective across the dying trajectory stems from their belief system; faith; values; moment of death. 34 Landmarks-based life’s purpose; and perception of the meaning of their existence in relation to others, including family members and close friends, nurses, physicians, social workers, and pastoral counselors. 37 Spiritual distress is just as critical as body and mind distress. 37 A spiritual approach to coping with dying can enhance the
In 1969, Viktor Frankl argued that the main goal in a person’s life is to actively create and find meaning and value in life. This reflective process at the end of life includes emotional, physical, cognitive, behavioral, and spiritual exploration, and it helps many to find understanding and positive transformation. :9 ● Emotional component : Exploring one’s feelings about a diagnosis with a terminal prognosis. ● Physical component : Coping with bodily changes and any significant suffering. ● Cognitive component : Thinking about adapting to what is and leaving behind what was. Theoretical models In addition to finding meaning, a variety of theoretical perspectives can help guide the way in which clinicians provide support to those coping with death and dying. These theories can be applied from the time of diagnosis to the time of death. Theoretical models of the dying process help clinicians intervene appropriately and offer the best quality of life for these patients. Theoretical models of the dying process include stage-based, awareness-based, task-based, phase-based, landmarks-based, and spirituality-based models. Stage-based The stage-based approach to coping with dying is the most familiar among healthcare providers. This groundbreaking work by Elisabeth Kübler- Ross 31 outlined emotional stages of the dying process and includes five stages of grieving, or accepting death: denial, anger, bargaining, depression, and acceptance. 31 What this model can teach clinicians is that the underlying philosophy of the stage-based model is not to manipulate and move those with a life-threatening disease through transitions and milestones as death approaches; stages do not occur in a fixed sequence or timeline. 32 Task-based While dealing with each phase that brings the patient closer to death, there are certain tasks that need to be accomplished while living with life- threatening illness, which have been divided into four areas of taskwork. 33 ● Physical tasks involve managing bodily needs and minimizing physical distress, such as by controlling pain and constipation. ● Psychological tasks maximize psychological security, autonomy, and richness in living. ● Social tasks enhance significant attachments and This model teaches clinicians who work in palliative care and hospice care that as individuals find ways to manage their bodily changes, attempt to maintain a healthy mental perspective, and cherish their relationships, they are also exploring what is sacred to them in the time they have left. Phase-based The phase-based theory of dying process focuses on the living-dying interval that occurs from when the address the social implications of dying. ● Spiritual tasks address meaningfulness, connectedness, and transcendence.
Book Code: MI24CMEB
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patient’s life and can be instrumental for those who have a life-threatening disease and for their family members. 37 Although chaplains, community-based clergy, and pastoral counselors recognize and explore spiritual distress, all professional care providers can inquire into this significant part of the patient’s being. Bowman notes that spirituality is now routinely included in palliative care and that spiritual care is not synonymous with religious practice. 38 This difference
may cause tension for those providing end-of-life care because, all too frequently, patients near the end of life may reveal things when ready to clinicians with whom they experience comfort; clinicians need to be ready to address any spiritual and grief concerns when voiced. 38 Accordingly, a palliative care team may help patients and families move toward acceptance and peace if they are challenged by the illness and are looking for spiritual support. 39,40
COMMON MYTHS AND BARRIERS
Although hospice and palliative care allow patients autonomy to deal with their own illness, there are still misconceptions that contribute to fear and resistance. These misconceptions cause barriers to care delivery. Many people consider hospice synonymous with death, giving up hope, euthanasia, or assisted suicide. Zimmermann and colleagues found when palliative care was introduced to patients, they reported feeling shock and fear, resistance to it, and a lack of relevance to them. 41 Common myths of hospice and palliative care Myth #1: Hospice is a place. False : Hospice is a philosophy and hospice care takes place wherever the patient calls home. Myth #2: Hospice is only for people with cancer. False : More than one-half of hospice patients have diagnoses other than cancer. Hospices serve patients with end-stages of chronic diseases such as COPD, Alzheimer’s, cardiovascular, and neuromuscular diseases. Myth #3: Hospice is only for old people or the last week of life. False : Although most hospice patients are older, hospices serve patients of all ages and may continue to serve patients who outlive their initial prognosis Myth #4: Hospice means patients can no longer choose their care. False : As a family-centered concept of care, hospice focuses as much on individualizing care for the patient and the grieving family as on the dying patient. Patients may decide to return to curative care and be discharged from hospice. Myth #5: Hospice can help only when family members are available to provide care or when hospice is staffed by volunteers. False : Recognizing that terminally ill people may live alone or with family members unable to provide care, many hospices coordinate community resources to identify a location for the patient to receive care. Hospices are staffed by professionals with volunteers as integral members of the team. Myth #6: Hospice means the patient will die faster . False : Hospice and palliative care is serious medicine and can be quite high-level care. Most hospices are Medicare-certified, requiring that they
employ experienced and highly skilled medical and nursing personnel. Hospice is about making the most of the remaining time. Myth #7: Hospice requires a doctor referral. False : Anyone can refer to hospice for a consultation, even the patient or family. If the patient is deemed appropriate, an order from a physician is required before care can be performed. Myth #8: Hospice care is expensive. False : Most people who use hospice are entitled to the Medicare Hospice Benefit. This benefit covers virtually all hospice services and requires little, if any, out-of-pocket costs for hospice benefits where services are covered. Myth #9: Patients are required to have a Do Not Resuscitate (DNR) order for hospice care. False : Having a DNR in place is not a hospice requirement. Myth #10: Hospice is for when there is no hope. False : Hospice is a shift in care to focus on comfort. It does not mean there is nothing that can be done; hospice is something that can be done to help the patient maximize their time left. Other barriers to the delivery of hospice and palliative care include both the education and training of healthcare providers in this specialty area. The National Consensus Project for Quality Palliative Care (NCP) aims to formalize and delineate evidence- based processes and practices for the provision of safe and reliable high-quality palliative care in all care settings. 42 The overview and scope of the 4th edition of the NCP Clinical Practice Guidelines for Quality Palliative Care is to: ● Improve access to palliative care for those with serious illness in all care settings by integrating palliative care principles and best practices into routine assessments and care; ● Formalize evidence-based practices for palliative care for seriously ill adults and children in all care settings; and ● Provide guidelines to assist in developing palliative care reimbursement mechanisms that are linked to standardized care, as payers (e.g., Medicare Advantage plans) are exploring ways to pay for better access to palliative care. 42
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Book Code: MI24CMEB
Conclusion This course provided an overview of hospice and palliative care and illuminated the importance and recent growth of this specialty area. It also included a focus on hospice services as defined by the Medicare hospice benefit, quality metrics, and the delivery of care. Increased understanding by nurses and other clinicians is crucial to providing compassionate care. The goal of hospice and palliative care is to https://agingwithdignity.org ● American Academy of Hospice and Palliative Medicine http://aahpm.org ● American Association of Colleges of Nursing End of Life Nursing Consortium https://www.aacnnursing.org/ELNEC ● CaringInfo (National Hospice and Palliative Care Organization) https://www.caringinfo.org ● Center to Advance Palliative Care https://www.capc.org ● Centers for Medicare and Medicaid Services Resources ● Aging With Dignity https://www.cms.gov/Medicare/Medicare-Fee-for- Service- Payment/Hospice#:~:text=Hospice%20 Levels%20of%20Care,enrolled%20in%20the%20 hospice%20benefit.&text=A%20patient's%20 ● Dignity in Care https://dignityincare.ca/en/
reduce the patient’s distressing symptoms (physical, psychological, social, and spiritual), no matter how young or how old they are, and to improve their quality of life. Making appropriate and timely referrals for hospice and palliative care is one way that clinicians can prevent needless suffering for patients with life-limiting conditions. ● Hospice and Palliative Nurses Association https://advancingexpertcare.org ● Hospice Foundation of America https://hospicefoundation.org ● National Association for Home Care & Hospice https://www.nahc.org ● National Hospice and Palliative Care Organization https://www.nhpco.org
WORKS CITED https://uqr.to/HPCare
Book Code: MI24CMEB
Page 9
HOSPICE AND PALLIATIVE CARE FOR HEALTHCARE PROFESSIONALS Final Examination Questions Select the best answer for each question and mark your answers on the Final Examination Answer Sheet found on page 59, or complete your test online at BOOK.CME.EDU 1. All of the following are domains of palliative care EXCEPT: a. Psychological and Psychiatric.
8. Online resources available to healthcare providers: a. Are limited by the Hospice Medicare Benefit (HMB). b. Are available only to those specializing in hospice and palliative care. c. Are readily available from private and governmental agencies. d. Are healthcare institution specific. 9. Hospice care is intended: a. To focus on patient comfort. b. To accelerate the time to death. c. To be available only to those individuals >65 years old. d. To provide services exclusively to the patient. 10. Theoretical models of dying are theories that: a. Consider patients financial status for available services. b. Guide support to those coping with death and dying. c. Are fixed, following a specific order. d. Are purely clinical and exclude spirituality.
b. Spiritual and Existential. c. Physical aspects of care. d. Financial aspects of care.
2. Hospice care:
a. Is available only to those individuals expected to live one month or less. b. Is synonymous with “DNR.” c. Is a component of palliative care. d. Is limited to withdrawal of care in an ICU. 3. The most common primary diagnosis associated with hospice care is: a. Cancer. b. End stage renal disease. c. Dementia. d. Heart Disease. 4. All of the following are believed to contribute to racial disparities in hospice usage EXCEPT: a. Trusting the healthcare system. b. Faith beliefs. c. Economic factors. d. Access to care. 5. The median length of stay for Medicare patients receiving hospice care was: a. 2 days. b. 18 days. c. 8 weeks. d. 18 weeks. 6. Levels of hospice care as defined by Medicare include all of the following EXCEPT: a. Routine home care. b. Continuous home care.
c. Respite care. d. Intensive care. 7. Pediatric palliative care:
a. Aims to meet developmental needs of patients. b. May include weekend retreats. c. May include expressive arts therapy. d. All of the above.
Course Code: MI24CME-302
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Book Code: MI24CMEB
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