Q&A: Hospice care supports patients with end-stage pulmonary conditions

When advanced, chronic pulmonary conditions, such as COPD, worsen, physicians may recommend these patients consider hospice care.

“Hospice offers comprehensive and individualized services to help support patients with end-stage pulmonary conditions,” Joseph Shega, MD, executive vice president and chief medical officer at VITAS Healthcare, told Healio. “The purpose of hospice is for patients to be able to remain comfortable by receiving care at home, if they wish, and to have management of symptoms."

Healio spoke with Shega about who qualifies for hospice, the benefits of this type of care for patients and families, and what the transition to hospice looks like.

Healio: What pulmonary conditions may be eligible for receiving hospice care?

Shega: Pulmonary conditions such as COPD, emphysema, chronic bronchitis, chronic asthma, bronchiectasis, pulmonary fibrosis and cystic fibrosis could all progress to a point at which a patient is eligible for hospice care.

Healio: What criteria does a patient have to meet to be eligible for hospice care?

Shega: One note that is incredibly important and is often misunderstood by patients, families and sometimes even health care professionals is that patients qualify for hospice when they have a prognosis of 6 months or less. Hospice care is not only for a patient’s last days or weeks of life.

In general, two key characteristics must be met for a patient to be hospice-eligible: one relates to disease severity, and the other, to ongoing disease progression.

Disease severity is generally marked by the experience of shortness of breath (also known as dyspnea) while at rest or with minimal exertion and on oxygen therapy. Also, a patient may exhibit unintentional weight loss and an increased dependence while trying to perform daily tasks, such as bathing or going to the bathroom.

Disease progression often presents itself when disease-modifying treatments are no longer effective and is evidenced by increased health care utilization, such as emergency room visits or hospitalizations. Common reasons for these visits include respiratory issues, exacerbated breathing problems and/or lung infections (eg, bronchitis, pneumonia, etc). Often, patients report no longer wishing to be hospitalized or in the ICU.

Physicians should ask key questions when determining when to refer a patient with an advanced lung disease to hospice:

• What percentage of a patient’s waking hours are spent sitting/lying down/resting? An answer of 50% or more is a sign of functional decline and likely eligibility for hospice referral.
• Does the patient exhibit symptoms, including cough, wheezing or shortness of breath, with minimal exertion or at rest?
• Does the patient require assistance with three or more basic activities of daily living (bathing, dressing, continence, ambulation, transfer or feeding)?

If a patient is experiencing these symptoms or answers “yes” to these questions, it may be time for the clinician to discuss a transition to hospice care.

Healio: How can pulmonologists educate their patients about the benefits of hospice care and support them in their transition?

Shega: Initiating advanced care planning (ACP) conversations is incredibly beneficial in helping patients document their wishes and make their desires for end-of-life care known to family and their medical team.

Having honest and timely conversations about a patient’s care priorities, including end-of-life goals, will ultimately lead to a higher likelihood that the patient will achieve their goals and have their wishes fulfilled at end of life.

It is the physician’s responsibility to help a patient understand when their pulmonary condition has progressed to the point at which they need hospice care, as well as the care options available to support them. I recognize these conversations can sometimes be completely new for patients and families, and they may need to think about and consider their goals for end-of-life care. That is why it is important for physicians to bring up ACP early and give ample time for patients to make end-of-life plans. Unnecessary suffering could be prevented by patients having their wishes documented ahead of time, so they can start receiving comfortable care at home rather than potentially suffering while decisions are being made.

When having these discussions, pulmonologists should carefully explain the patient’s current condition and their care options. They should invite the patient to ask questions and respond with empathy. These conversations are what make a world of difference for the patient when they near end of life.

Healio: What benefits/services does hospice care offer to patients with pulmonary conditions?

Shega: Hospice provides all medications related to a patient’s pulmonary condition, as well as equipment. Equipment often includes oxygen, suction, nebulizer, a hospital bed, bedside commode, tray table, wheelchair and other pieces of equipment. Also, on a case-by-case basis, hospice may support high-flow oxygen; bilevel positive airway pressure, or BiPAP; Airvo (Fisher & Paykel Healthcare); or Trilogy (Respironics).

Oftentimes, patients with pulmonary conditions are concerned about what will happen if they aren’t able to breathe. That is why the hospice team develops a plan with the advice of the patient’s pulmonologist, respiratory therapist and the hospice physician. Together, they outline specific interventions to keep respiratory distress and severe symptoms under control at home. Patients and their families are given peace of mind by knowing a pre-emergency plan is in place. Hospice clinicians are trained to help patients overcome feelings of fear, anxiety and isolation that often accompany respiratory distress.

Hospice care also prioritizes patients’ emotional and spiritual wellbeing through several resources including music therapy, pet visits and pastoral care, upon request.

Healio: What does the transition process into hospice care look like?

Shega: The transition from chronic disease management to hospice care can be emotional, and that is why a team of hospice specialists including a physician, nurse, hospice aide, social worker, chaplain and volunteer guide the patient and family through every step of the way.

One common misperception is that hospice won’t incorporate treatment when symptoms worsen from disease exacerbation. However, we commonly do standard treatments to help with symptoms, such as pulse steroids, increased oxygen and antibiotics.

Hospice staff is equipped with medical equipment to help the patient physically transition to hospice, such as a wheelchair, hospital bed, oxygen or anything else the patient may need. Care teams carefully explain to the family the steps they plan to take and what is happening to their loved one. Hospice teams will then continuously manage pain, deliver care and provide information and reassurance to the family.

Healio: How do families and caregivers also benefit from hospice care?

Shega: Families and caregivers benefit from hospice care in many ways. Feedback we often hear from families is that the support from the hospice teams is one of the greatest benefits of hospice care. Education and training help families learn how to best care for their loved ones, even as communication becomes more difficult. Families can lean on hospice teams when making tough choices involving their loved ones, because even the most experienced caregivers will still have questions and concerns. With around-the-clock support, caregivers and families won’t have to wonder, worry or wait for an answer. After the patient passes, the hospice team works with surviving loved ones for over a year to help them express and cope with their grief.

References:

• VITAS Healthcare. Hospice care for lung disease patients. https://www.vitas.com/care-services/personalized-care-plans-by-diagnosis/lung-disease. Accessed Nov. 30, 2022.

For more information:

Joseph Shega, MD, can be reached at media@vitas.com.