Advanced Certified Hospice And Palliative Social Worker: Fill & Download for Free

I can relate. When my mother learned from her doctors that "there really isn't anything more we can do" for her advanced lung disease, we both knew it was "time for hospice." But even though I work in the field and we'd talked often about the possibility, and her husband had died well with hospice care about 2 years earlier -- boy it wasn't easy to make that call.Deciding to enroll in hospice can be extremely difficult, even for patients and family members who are well informed and realistic about where a disease process is headed. In the United States, Medicare rules have created additional, artificial barriers by requiring doctors to certify that the patient is terminal and is expected to live only 6 months or less, and by requiring patients to forego any further curative treatment. Many people -- patients, family members, and even physicians -- see all this as "giving up" not only on any prospect of a cure, but on life itself. We're just not wired that way.Story after story, and study after study, however, have demonstrated that hospice care can not only improve how patients experience their lives but also how long they live! The biggest complaint we (in the hospice field) hear is that patients did not enter our care sooner. Still, resistance exists, and it is real. More often than not, however, it's based on misinformation or fear.So the first step would be to ask (respectfully, gently) the patient to say why they won't consider hospice care. Here are some possible concerns and ways to relieve them:1. "Doctors can be wrong -- what if I'm not terminal or live longer than six months?"Yes doctors can be wrong, and the hospice team will do their own assessment of your situation before you enroll. Assuming you meet the clinical criteria to enroll, the first benefit period is 90 days, followed by another 90 days, and then 60-day periods after that. At the end of each benefit period, your condition and records are reviewed. As long as you continue to meet the clinical criteria, you may stay enrolled in care. It's not common, but some people are in hospice care for many more than six months. But also, you might "graduate" from hospice care -- every year about 13% of hospice patients are discharged or leave hospice prior to death, because they decide to resume curative care, change providers, or because they have gotten better -- which is a good thing!2. "I'm not ready to give up -- maybe another treatment will come along that can help me!"Great! A patient who enrolls in hospice can check out ("revoke") at any time to resume curative care. And they can re-enroll if they meet clinical criteria. Also, treatments that you might think of as "curative" -- some chemotherapies or radiation, for instance -- can actually have a powerful palliative (or comfort-oriented) effect and thus might be covered by hospice.3. "Hospice is where you go to die -- they just take away all your meds, pump you full of morphine, and you're gone in a few days."First, more than 96% of hospice care is delivered to patients in their own homes. If patients can't be cared for at home, hospices have arrangements with nursing facilities and some have their own residence (typically much more homelike than nursing homes) for inpatient care, but hospice isn't usually a "place" at all.Second, the hospice team will review all your current medications and may recommend that you discontinue some if they are not contributing to your comfort. This can be alarming to patients, but very frequently reducing the number and complexity of patient's medications can have great benefits. We often see patients experience a kind of "bounce" as their bloodstreams and brains clear of all the powerful drug effects and interactions. Any medications that are helping you feel or function better will likely be continued.Third, hospice clinicians have a broad and very sophisticated set of treatment tools, including drugs, they use to control pain, make it easier to breathe, control anxiety, ease fatigue or nausea or any distressing symptom. Morphine is just one of the drugs used. Hospice care also pays attention to emotional distress, psychological issues, and even spiritual concerns, and they look after family members as closely as they care for patients. The hospice team comprises a nurse, nurse's aide, physician, social worker, chaplain, and volunteers who work together to make every aspect of the patient's life as comfortable and pain-free as possible. That said, the only member of the team the patient really has to see is the nurse -- everything else is optional, and patients and families are closely consulted about what they need and want in terms of care. While it's true that about half of hospice patients are in hospice care for less than a month, it's mostly because they or their physicians waited way too long to start care.4. "I can't possibly afford hospice care on top of all the other medical bills I'm paying!"For Medicare patients, hospice is a fully covered Part A benefit. Hospices are paid a (very modest) per-diem amount, and they cover the expenses for the services of the entire hospice team, all the drugs, equipment, and supplies required by the care for the terminal condition. If the patient needs treatment for something unrelated to the terminal disease (say, they break a bone), that care is covered by Part B. If the patient doesn't have Medicare, most private insurance plans and Medicaid programs have benefits modeled on the Medicare Hospice Benefit. In rare cases, when patients have no insurance coverage at all, many hospices have a strong commitment to providing care regardless of a patient's ability to pay.5. "I really like my doctor, she's seen me through so much, I don't want to get someone new at this stage."While all hospices have staff or contract physicians they work with, many of whom have specialized training in hospice and palliative care, patients can keep their own doctors when they enroll in hospice. Your current doctor can continue to supervise your care, coordinating with the hospice medical director and team.If after all these explanations, the patient still baulks, you can suggest that they just "give hospice a try" and if they don't like it, they can check out! My mother, even with a strong dose of realism and no desire to pursue painful and burdensome treatments with little chance of really curing her, still hesitated. We both shed tears over what it likely meant for her. And then I said, "Try not to think of it as the end of the road -- just think of it as the best possible care you can get, brought to you at home!" That helped, I think. She came to love and look forward to visits from her team. She was in hospice care for almost a full six months. I'm pretty sure she lived a lot longer than she would have without it, and I am absolutely certain she lived a lot better. So did I.

I'm not a physician, so can only answer second-hand from what I've observed and heard from my physician friends and colleagues.Most rewarding:The "luxury" of time to have meaningful and in-depth conversations with patients and families about their experiences, current status, and hopes and goals. One doc I know characterized the family meeting (i.e., consult) as the "palliative care procedure." Surgeons do surgery, palliative care docs do consults. And it takes just as much skill, training, practice, and nerve as performing surgery. Many patients or their family members have never really been asked "What's most important to you now?" or "What do you understand is going on with you right now?" or "What are your goals for your treatment?" An oncologist's goal for a patient's treatment might be to pursue yet another line of aggressive chemotherapy to slow down the advance of the cancer. But the patient's goal might be to get strong enough to play with his grandchildren. Sometimes the treating physician's goals and the patient's goals are congruent; sometimes completely divergent. The palliative care doc and team are often the ones to uncover that and work as intermediaries to plan a way forward.The other thing palliative care docs/teams do is work to relieve distress, with highly specialized knowledge of pharmacological and other interventions to reduce pain, ease breathing, alleviate fatigue and anxiety, calm nausea, and so on. So often these "side effects" of treatment are either ignored or minimized as just the price one has to pay for "curative" treatment. Relieving suffering is really the fundamental goal of all medicine, and palliative care docs have it as their prime directive. The effect on patients -- able to breathe, think, sit up, talk, eat, interact, sleep, etc. for the first time in weeks or months -- is hugely rewarding. Palliative care also addresses emotional, spiritual, and psychological distress, though these aspects are usually covered by members of the team other than the physician.Many palliative care docs find the interdisciplinary team aspect of palliative care very rewarding. The opportunity to benefit from different perspectives, in real time, not only provides additional insights and expertise, it distributes the load of responsibility and creates consensus within shared decision making. It's not always an easy or natural thing for a doctor to listen respectfully and really take into account the observations of a social worker or nurse or chaplain, but those that do find it very enriching. (Of course, a lot of palliative care "programs," especially in smaller hospitals, are just the doc or maybe a doc and a nurse, so not all of them are getting the full interdisciplinary experience.)Hardest parts:Getting involved with the patient's situation too late. Palliative care is designed for patients coping with any serious OR chronic OR life-limiting illness, but too often, like hospice, it's suggested and utilized way too late in the disease trajectory, when patients have completely exhausted life-extending therapies and been exhausted by the process. Then someone says, well, we should probably just focus on keeping you comfortable and instead of saying the dreaded "h" word (hospice), the person says, "We have this great service called palliative care. . . ."Relatedly, palliative care is often invoked only when a conflict over the treatment plan arises. It used to be that when the patient's doctor wanted (for instance) to pursue another line of aggressive treatment and the patient or family said no (or, sometimes vice versa-- the doc would want to stop but the patient/family might insist on "doing everything"), someone would call the ethics committee, and they'd have to defuse the conflict and propose a way forward. Now, it's the palliative care doc/team that gets called and sometimes they are stepping into a situation that is not only clinically complex but has become adversarial. One doc I know expressed it this way: "When someone wants to pull the plug and someone else doesn't, we get called -- we're like the Ghostbusters of medicine!" And each party in the conflict is hoping/wanting the palliative care team to push the other in a particular direction, which is not the point at all of the consult. About the best that can be done in these 11th-hour situations is to make the patient comfortable, defuse the conflict and reach some agreement about the ongoing care plan. But -- that's still a big win.The other very hard part about being a palliative care doc in the U.S. is that it's a bit of a red-headed stepchild in the medical family. (Speaking as a red-headed stepchild myself, and not meaning any offense to any others out there!) Palliative care is not even remotely adequately reimbursed, so docs and programs are constantly fighting for funding and support from their institutions, spending inordinate amounts of time making the financial case for their work by tracking cost avoidance or other benefits to the facility or system, and every day having to prove their worth on numerous levels. On the status totem pole of medical specialties, it could be even a notch below family practice as a "cognitive" discipline without (usually) any kind of clinical home. In short, it's not sexy and it doesn't get much respect. Until recently, it was often a mid-career choice for docs who were already long established as family practitioners, internists, or geriatricians. Until about 2010 (I think that was the year), it was possible to get board-certified in palliative medicine via exam alone; now a fellowship is required. Needless to say not a lot of mid-career physicians are willing to do that again and not very newly minted medical students are keen to go into a specialty that isn't going to pay off their student loans before the third millenium.All that said, the field is dynamic, growing, and by sheer force of demographics and economics will continue to gain in importance. There's a huge opportunity for docs coming in to the specialty to make a significant difference not only in the lives and deaths of individual patients but in healthcare systems writ small and large. It's a small pond with lots of scope for big fish who want to change the world.