Sourcebook : 16.2 Ways to Identify and Enroll Patients : 16.2.2 Case Study - Hope Hospice

In its program, Florida's Hope Hospice also found cardiologists and primary care doctors reluctant to refer cardiac patients to hospice for fear that referrals were being made "too soon." However, Hope reviewed its data and found that the opposite was true: Between 1993 and 1995, 35 percent of its cardiac patients died within two weeks of referral, and 72 percent died within 90 days.

Hope used several strategies to increase cardiac referrals, including:

Having daily discussions with discharge planners at local hospitals, telling them to refer patients who had an ejection fraction of 20 percent or less, were not candidates for surgery, and had recurrent hospital admissions and/or desired to avoid future hospitalization.
Providing cardiologists and cardiac surgeons with referral information
Having a hospice nurse liaison visit cardiology offices
Collaborating with local hospitals to admit patients to hospice while still hospitalized

Admission Orders to Hope Hospice-Cardiac

Admit to Hope Hospice.
Death certificate: I or covering physician will sign.
Do not resuscitate.
Diet as tolerated.
Dyspnea: O2 2-4 L prn.
Anxiety: Lorazepam (liquid or tabs) 0.5-1 mg po or sl q 4 prn.
Diarrhea: Imodium AD 2 mg after each loose stool to maximum 16 mg/24 h.
Constipation: Senokot-S 1-2 po qd prn constipation.
Fever: Acetaminophen 650 mg po or pr q 4 h prn for temperature greater than 101O F.
Difficulty voiding: Foley/condom catheter prn; replace prn; irrigate with sterile saline prn; Lidocaine jelly 2% 10 cc prn for insertion.
Urinary symptoms: Urine reagent strips for urinalysis.
Nurse/pharmacist to instruct patient/family/caregiver in all aspects of medication administration and treatment modalities prn.
Hope Hospice physician to give orders in my absence.
Hospice physician may see patient at home.
See attached list for additional medications and orders.
Follow Hope Hospice protocol for chest pain.
For acute congestive heart failure follow cardiac chest pain protocol plus:
__Furosemide 80 mg IV or
__Furosemide ___ mg IV or
__Other: _________________________________.
Weigh every visit and prn CHF symptoms. If weight gain equal to or greater than 4 pounds give Furosemide ___ mg IV.
Cardiac comfort care kit.
Labs:
__ no labs
__ electrolytes, BUN/Creatinine before dobutamine
__ electrolytes, BUN/Creatinine q ____ months
__ INR q ___ months
__ Digoxin level q ____ months
__ Do not call normal labs to attending

Verbal orders received by: ____________________R.N. Date ____________

Physician: ____________________________ Date ____________

INR	a test of clotting
qd	daily
q4	every 4 hours
BUN	a test of kidney function
po	by mouth
IV	intravenous
prn	as needed
sl	sublingual

Hospice nurses are generally experienced and trained in oncology care. Hope Hospice provided its nurses training to assess and treat:

Chest pain
Cardiac pain
Congestive heart failure
Cardiac dyspnea

Assessment of Chest Pain
Indicators of Probable Ischemic Cardiac Origin	Other Etiologies to Consider
Pressing Squeezing Weight-Like Substernal Radiation Clenched Fist Dyspnea Nausea Vomiting Diaphoresis Like usual angina Post-exertion Cardiac diagnosis	Other Cardiac Pneumonia Pneumothorax Pulmonary Embolism Thoracic Aortic Dissection Pericarditis Esophagitis Peptic Ulcer Disease Acute Cholecystitis Herpes Zoster Chostrochronditis
Assessment Protocol for Pulmonary Embolus with Palliative Care Only
If: Acute Dyspnea Tachycardia Hx: DVT, PE, Malignancy, Immobilization Think: Possible Pulmonary Embolism	To assure comfort if no hospital treatment desired: Call hospice MD Initiate Palliative Care Morphine (neb, subc, iv, po) Lorazepam Pentabarb O₂ 2-4L/min
Assessment Protocol, Pulmonary Embolus with Usual Treatment
If Acute Dyspnea Tachycardia Hx: DVT, PE, Malignancy, Immobilization Think: Possible Pulmonary Embolism	For Treatment Aimed for Survival: Patient could have anticoagulation Confirm with call to attending MD O₂ 2-4 L/min Arrange for emergency transport to hospital Be especially gentle with movements – avoid further emboli

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This online version of the book Improving Care for the End of Life: A Sourcebook for Health Care Managers and Clinicians is provided with permission of Americans for Better Care of the Dying [ www.abcd-caring.org ] and Oxford University Press. All rights reserved.

For further information on quality improvement in end-of-life care visit The Palliative Care Policy Center [ www.medicaring.org ].