Objective and Interventions for the End of Life Community in

Concord, North Carolina

Objectives

• An increase in the quality of end of life care in the community will be achieved by
increasing the knowledge of the medical community regarding end of life care
and guidelines for making appropriate referrals to end of life care services. This
increase in quality of end of life care will be evidence by an increase in the
number of days on hospice services in the community from approximately 7 days
to 15 days within one year of initiating healthcare provider education and
outreach programs. In addition, a survey will be completed in one year from
initiation of educational programs that will assess healthcare providers
understanding of hospice service and criteria for making appropriate referrals to
end of life programs, 50% of healthcare providers surveyed will show adequate
understanding of these concepts.
• Throughout the community, there will be in increase in knowledge of end of life
services and utilization of these services to increase the quality of life in the end
of life community. This will be achieved be designing and implementing a
community outreach program that focuses on educating people about the benefits,
services for patients and families, referral criteria and dispel common myths
regarding end of life services. An increase in knowledge and utilization of end of
life services will be evidenced be a 20 percent increase in the total number of
hospice patient care in 2011 when compared to 2010.
The above objectives directly relate to Healthy People 2010's Goal 1 of increased life
expectancy and improve quality of life. It also addresses the objective of improved health
communication to inform and influence individual and community decisions that enhance
health. Although the focus of end of life care is comfort care rather than improving
health, improved communication by the healthcare community regarding end of life care
could greatly enhance the quality of life of the terminally ill. This goal specifically states
that good health communication can increase the demand for appropriate health services
and decreased demand for inappropriate health services. By educating about service like
hospice and palliative care, people can choose to utilize comfort care measure rather than
enduring painful often-unnecessary curative treatment, which does not increase the
quantity or quality of their life.

Intervention 1
Provide community education to end of life patients and families regarding Hospice
and Palliative Care of Cabarrus County services and other aspects concerning the
utilization of hospice and palliative care.

1. Provide training to hospice and palliative care staff on services offered by Hospice
and Palliative Care of Cabarrus County, benefits associated with the care provide and
techniques for educating the public on hospice and palliative care services.

2. Educate healthcare staff in the community in particular those working at assisted

living centers, retirement homes, hospitals, and other agencies about hospice and
palliative care services.

a. Provide fact sheets

b. Hold information sessions.
c. Provide information in prescheduled meetings the facility is holding.

3. Formulate a community outreach and education program, which includes staff of

hospice and palliative care, in the Cabarrus County area to educate residents about
hospice and palliative care services.

4. The staff of hospice and palliative care will increase public awareness about hospice
and clear up misconceptions of hospice services by:

a. Visiting community retirement and assisted living centers and performing

presentations on hospice and palliative care services.

b. Visiting community events and health fairs.

c. Creating posters appealing to the public with contact information to Hospice and
Palliative Care of Cabarrus County in which residents throughout the community can ask
questions about hospice and palliative care services. Post the posters in healthcare
facilities such as hospitals, doctor’s offices, outpatient clinics, health departments, and
living centers.

d. Creating brochures listing information about hospice and palliative care and clearing
up any misconceptions about the services they provide. Make these brochures accessible
to residents by placing them in healthcare facilities such as hospitals, doctor’s offices,
outpatient clinics, health departments, and living centers.

e. Holding forums at local retirement centers and nursing homes to allow families and
residents to ask questions about hospice and palliative care and clearing up any
misconceptions associated with its services.

5. Collaborate with the cultural groups in the community to reach out to minority groups.
The community assessed was culturally diverse and large segments of the population
were made up of African Americans and Hispanics in addition to the Caucasian
population. In order to develop community outreach programs that will increase the
utilization of hospice and palliative care by these minority groups, it is necessary to
identify ways to reach out to and meet the needs of these individuals.

a. Provide resources in a variety of languages, including brochures and posters.

b. Have accessibility to translators when carrying out presentations and informational

sessions about hospice and palliative care services.

c. Gain an understanding of these cultures beliefs and attitudes about death and dying and
how hospice and palliative care services can be incorporated into these belief systems to
improve quality of life during the dying process.

6. Create support groups for family members and friends affected by death and dying
and provide information on how to care for loved ones.

Intervention 2:
Hospice and Palliative Care of Cabarrus County will create an educational program
to increase the knowledge of end of life services by healthcare providers, focusing on
physicians in the community.

1. Physicians overestimate life expectancy of their patients (believe that the patient will
live longer than six months). In one study, 59% of 147 physicians reported that making a
prognosis of remaining time to live was the most frequent barrier to discussing the
hospice option of care (McGorty & Bornstein, 2003).

Intervention: During in-service hospice education, the hospice nurse or worker will
discuss with physicians the use of standardized scales such as the Palliative Performance
Scale to assist in determining life expectancy following diagnosis. The Palliative
Performance Scale uses functional level to predict survival time. Although patients and
diseases may have variable survival times, the scale has been proven to assist in
predicting the point that the patient is in progression of the diagnosis.

Review of the Literature: A study of 492-deceased patient’s charts in a home-based

hospice program that assigns a PPS score at the beginning of admission found that lower
scores on the scale directly related to fewer days of survival. Median survival was six
days for the 30% or lower group, 19 days for the 40% group, and 34 days for the 50% or
higher group (Weng, Huang, Wilkie, Hoenig, Suarez, Marschke, & Durham). A scale
similar to the Palliative Performance Scale can be adapted to guide physicians during
care to know when it is appropriate to refer patients to hospice services.

Palliative Performance Scale (PPS)

% Ambulation Activity and Self- Intake Conscious

Evidence of Disease Care Level
100 Full Normal activity; no evidence of Full Normal Full
disease
90 Full Normal activity; some evidence of Full Normal Full
disease
80 Full Normal activity with effort; some Full Normal or reduced Full
evidence of disease

70 Reduced Unable normal job/work; some Full Normal or reduced Full

evidence of disease
60 Reduced Unable hobby/housework; significant Occasional Normal or reduced Full or confusion
disease assistance
necessary
50 Mainly Unable to do any work; extensive Considerable Normal or reduced Full or confusion
Sit/Lie disease assistance required
40 Mainly in Unable to do any work; extensive Mainly assistance Normal or reduced Full or drowsy or
bed disease confusion
30 Totally bed Unable to do any work; extensive Total care Reduced Full or drowsy or
 bound disease confusion
20 Totally bed Unable to do any work; extensive Total care Minimal sips Full or drowsy or
bound disease confusion
10 Totally bed Unable to do any work; extensive Total care Mouth care only Drowsy or coma
bound disease
0 Death
Source: http://www.stjohnhealthsystem.com/upload/file/Hospice/Palliative%20Performance%20Scale.doc

2. Physicians view hospice as the last resort and feel uncomfortable discussing this
option with patients. In a study of 147 physicians, 6% reported discomfort in telling
patients about dying issues as a barrier to discussing hospice. In the same study 16% of
physicians felt uncomfortable discussing the patient’s terminal diagnosis as a barrier to
discussing the hospice option (McGorty & Bornstein, 2003).

Intervention: Hospice nurses and other healthcare team members can use a role-playing
activity during in-service education to facilitate discussion of end of life and the
possibility of hospice with patients. The role-playing activity would encourage
physicians to be honest and more comfortable with sharing news that the patient may
benefit from hospice services.

A short video on the correct way to begin communication of the hospice program to the
patient as an option of care will be shown by the hospice nurse. The video will
incorporate Robert Buckman’s six-step protocol for breaking news to patients. This six-
step protocol was originally used to present a patient with poor prognosis, but it can be
adapted to present the patient with news of the hospice program to patients who may
view hospice negatively and as “the end”.

Review of the Literature: 92% of 914 medical students responded to a questionnaire that
they now had a firm plan for sharing bad news with patients using Buckman’s six step
protocol compared to 48% who responded that they had a firm plan prior to watching the
videos and taking part in the role playing activities (Garg, Buckman, & Kason).

The six steps presented in the educational video:

 • Starting-The physician will establish a comfortable physical setting with the
patient, use eye contact, and ask the patient who can be in the room.
• Ask the patient what information they already have been given on the hospice
program. Asking the patient information they have on hospice will uncover
myths or negative misinformation about hospice that the physician can then
address. This method will also present the topic to a patient who does not have
any knowledge of hospice.
• Find out how much information on hospice the patient wants at this time. By
asking the patient if they would like to hear more information on hospice, the
physician will identify if the patient is emotionally ready and open to the option of
hospice care at this time in their treatment. A patient who does not want to hear
more information may be in denial and may either need more time to process the
prognosis.
• Give the information. Physicians can share their knowledge of hospice with the
patient. The physician can now present to the patient the information that they
have received from hospice workers about the program. This information will
include the purpose of hospice, who is involved in care, and Medicare eligibility
for hospice care.
• Respond to the patient’s feelings and questions about the hospice option. The
physician needs to be sensitive and understand that the patient may still have
feelings of hesitation and fear regarding hospice. By asking the patient how they
are feeling at this time, the physician can possibly alleviate patient anxiety about
the program.
• Plan and following up: If the patient expresses interest in entering hospice, the
physician should now contact the hospice representative and collaborate with the
representative on forming a plan for future patient care.

After the video, the hospice representative will present a case study of a terminal patient
and conduct a role-playing activity in which the physicians can utilize the six steps
presented in the video to begin communication of the hospice program with the “patient”.
92% of 914 medical students responded to a questionnaire that they now had a firm plan
for sharing bad news with patients using Buckman’s six step protocol compared to 48%
who responded that they had a firm plan prior to watching the videos and taking part in
the role playing activities (Garg, Buckman, & Kason).

3. According to a study of 147 physicians, physicians reported losing contact and

involvement with the patient and losing control of the patient’s care as a barrier to
communicating with patients about the option of hospice care (McGorty & Bornstein,
2003).

Intervention: The hospice nurse will identify a physician contact that is willing and
enthusiastic about improved hospice utilization that can be trained on hospice referral to
be the liaison between the hospice program and physicians at the hospital. Through
education, the physician will then be a resource for fellow physicians to consult on the
concept of hospice. Fellow physicians may be more open to learning about hospice from
a direct peer.

A brochure outlining the following purposes of hospice care and physician’s role with
hospice care will be provided to the physician and copies to be given to fellow
physicians:

Purpose

• Management of pain and symptoms of disease.

• Education for caregivers/family of the hospice patient on providing care.
• Assistance with activities of daily living and nutrition.
• Provision of medical supplies and medication.
• Counseling and social work services.
• Assistance with funeral arrangement and bereavement counseling.
Physician’s Role

The physician will be provided with in-depth information on the purpose and physician’s
roles with hospice care:

• Referral of patient to hospice care.

• Sign hospice certification order.
• Review the hospice care plan for your patient with hospice nurse, hospice
physician, or medical director.
• Prescribe medication for patient comfort and control of pain.
• Clinic visits/phone calls with patient.
• Collaborating with hospice nurses to determine needs for change in
medication or plan of care.
• Bill Medicare and insurance for clinic and at-home visits if applicable.

The above purposes and physician’s roles were adapted from the Horizon Hospice &
Palliative Care program.

Through education, the physician will then be a resource for fellow physicians to consult
on the concept of hospice. Fellow physicians may be more open to learning about
hospice from a direct peer.