An Educational Intervention to Decrease Drug Costs Related to Terminal Secretions in a Hospice Organization

Sights and Sounds of Respiratory Changes During Hospice Death Vigils: Hospice Caregivers Experience

CONTEXT

Research has documented common respiratory changes at the end of life for hospice patients. Some studies have noted these symptoms as distressing and challenging for families, and as a potential reason for emergency room visits and hospice benefit revocation. However, the experiences and emotions of family members regarding these respiratory changes in the final days, particularly when they are alone in a home setting, are not well documented. A recent study found 51% caregivers identified abnormal breathing as a challenge during their vigil experience.

OBJECTIVES

The study aimed to answer three research questions: 1) How do family members describe the sights and sounds of the respiratory changes experienced during the final days of life? 2) What are the emotions caregivers experience as a result of witnessing the sights and sounds of respiratory changes? 3) What interventions are caregivers using to manage respiratory changes?

METHODS

A secondary analysis of 22 hospice caregiver interviews from a larger study of family interviews focused analyzing in depth narratives related to respiratory changes during the vigil period.

RESULTS

Caregiver narratives distressful sights and sounds related to respiratory symptoms during the final days were described by 27% and 77% of family narratives, respectively. Negative emotional reactions were reported by more than a third of those interviewed. Caregivers expressed frustration at not understanding the reasons behind respiratory changes, with 27% noting they wished for more information on what to expect and how to intervene. There were inconsistencies in the interventions provided by hospice teams in managing respiratory symptoms.

CONCLUSIONS

Opportunities exist for hospice agencies to better address the caregiver distress caused by witnessing noisy breathing (death rattle), Cheyne-Stokes breathing, and agonal breathing. Further research is needed to identify standard definitions for these respiratory changes, their prevalence in the home hospice setting, and to develop practice standards and effective interventions to relieve caregiver distress.

Cost of Pediatric Concurrent Hospice Care: An Economic Analysis of Relevant Cost Components, Review of the Literature, and Case Illustration

Background: Concurrent care enables seriously ill pediatric Medicaid and Children's Health Insurance Program (CHIP) beneficiaries to continue curative treatments along with the supportive services usually associated with hospice care. Although a few studies have examined pediatric concurrent care, none has explored the economics of this care delivery approach for medically complex children. Objective: The purpose of this study was to identify the cost components relevant for an economic analysis of pediatric concurrent hospice care and demonstrate the use of the cost components in an economic case illustration. Methods: A scoping review of the hospice cost literature was conducted to identify article focused on hospice costs that were published in the journal literature from 2000 to 2019. A preliminary economic analysis was also conducted using a cost-minimization approach with data from a large mid-Atlantic pediatric hospice provider. We compared costs between concurrent versus standard hospice care for children. Results: Fifteen hospice cost articles were identified and no article on concurrent care costs. Most articles in the scoping review focused on hospice personnel costs, followed by supplies/equipment, and other. Personnel and costs were higher for standard hospice children compared with concurrent care, whereas concurrent care children had higher supplies/equipment costs. Conclusions: Identifying cost components are critical to economic analysis of pediatric concurrent care. These findings provide preliminary evidence about the difference in costs between concurrent and standard hospice care for children.

Analysis of Inpatient Hospice Pharmacist Interventions Within a Veterans Affairs Medical Center

Clinical pharmacy interventions have been shown to improve medication therapy, prevent undesirable side effects, and improve patients' clinical outcomes in a number of settings; however, limited data exist to characterize clinical pharmacy specialist (CPS) providers' interventions in an inpatient hospice Veteran Affairs (VA) setting. The primary objective of this quality improvement (QI) project was to quantify the number and types of pharmacy interventions implemented from the Pharmacists Achieve Results with Medications Documentation (PhARMD) tool for inpatient hospice patient encounters in a VA medical center. A total of 453 interventions during 185 patient care encounters were documented by CPS providers between September 1, 2016, and December 31, 2016. These interventions were documented across 32 unique patients, with an average of 14.2 interventions made per patient during this period. CPS providers frequently intervened to optimize pharmacotherapy for the treatment of pain (42.38%), terminal agitation (5.08%), and nausea (3.97%). Additionally, CPS providers played a significant role in the deprescribing of medication by discontinuing drugs no longer indicated (18.3%). These results substantiate the valuable contribution to patient care that the CPS providers make in optimizing symptom management and deprescribing at end-of-life. Future studies are needed to characterize the potential cost savings of CPS provider services in the inpatient hospice setting.