Cheryl Shapiro
Ferris State University
Learning Objectives
 To understand hospice
 To understand the philosophy of hospice
 To understand the barriers to hospice admission
 To understand that conversations about death are
 To understand how advanced directives can start
the conversation about death
 To start the conversation in one’s own life
The Hospice Philosophy
 “The purpose of hospice is to provide support and
care for people in the final phase of a terminal
disease so that they can live as fully and
comfortably as possibly. Hospice affirms life and
regards dying as a normal process. Hospice neither
hasten not postpones death. Hospice believes that
through personalized services and a caring
community, patient and families can attain the
necessary preparation for death that is satisfactory
to them” (National Hospice Organization, NHO,
What is Hospice?
 Takes care of those with a prognosis of six months or
less to live
Focuses on caring, not curing
Works to control pain and other symptoms
Recognizes dying as part of the normal process of
Affirms life and neither hastens nor postpones death
Offers grief support after the death.
Hospice Foundation of America (n.d.)
Who & Where
 Hospice Eligibility Requirements –
 “A Medicare patient must be certified by a
physician as being terminally ill with prognosis
of 6 months or less”
 Where do people use hospice?
 Anywhere the client calls home, including
moving to a facility if needed
(National Hospice Organization, 2014)
History of Hospice Care
 The inspiration for the modern hospice came from Dame
Cicely Saunders. Dr Saunders was an amazing woman of
vision and compassion. She received her medical degree in
1957 in the United Kingdom. At that time she became the
first modern doctor to specialize in helping dying patients
improve their quality of life.
 Crucial to understanding the emotional dying process is
Dr. Elisabeth Kubler-Ross,and her bestselling book, On
Death and Dying in 1969. Her book was written after
interviewing 500 dying patients. Kubler-Ross pleas for
home care and introduces the five stages of grief.
 Beginning in 1982, Medicare began to offer hospice as a
benefit. This changed theory into reality.
National Hospice and Palliative Care Organization, NHPCO (2010)
1. Death must be accepted
2. The patient’s total care must be managed by a skilled
interdisciplinary team whose members communicate
The common symptoms of terminal disease, especially the
treatment of pain in all its aspects, needs to be effectively
The patient and family must be recognized as a single unit of
An active homecare program should be implemented.
An active bereavement program must be provided for family
after the death of the patient.
Research and education should be ongoing .
(Sheehan,D., Forman, W., Kitzes , J. 2003, p.5)
What is the Difference Between
Hospice and Palliative Care?
Hospice Care
Palliative Care
 Focus of care is quality of life – Focus of care is quality of life –
not curative
 Strictly for end-of-life care
 Covered by Medicare
not curative
 Pain and symptom management
for those with a chronic,
debilitating illness.
 DRG reimbursement
Ideally, a patient would use palliative care first and
then flow naturally into hospice care if needed.
(National Hospice Organization, 2014)
Does Hospice Save Money?
 Hospice cancer patients used less medical resources for
non-hospice health needs.
(Breitkopf, Stephens, Jatoi,, 2013)
 Cancer patients who were discharged from hospice used
more health care resources.
(Breitkopf, Stephens, Jatoi,, 2013)
 Hospice patients were 16% less likely to die in a hospital
and used the emergency depart 11% less than their
(Alonso-Babarro, et al., 2012)
 Medicare saved $1.26 for every $1.00 spent on hospice care
(Hospice Association of America, 2010)
Ineffective Use of Hospice
 25% of hospice patients are enrolled for less than
one week . This, when maximum benefit is shown
to be 80-90 days.
 25% of deaths occur at home - more than 70% of
Americans would prefer to die at home.
(Hospice Association of America, 2010)
Root Cause Analysis
Barriers to effective hospice usage
Patients are uncomfortable talking about death
Doctors are uncomfortable talking about death
Hospice = Death
Hospice underused
Referrals made too late
Lack of advanced directive
Lack of hospice education
Culture of Death Denial
 Society
(Whittington , 2011)
 Entire culture hides and is protected of from death
 Hospice = death
 Physicians
(Tucker, 2009 )
 Physician’s lack education about death
 Physicians view death as a failure
 This causes a delay in hospice referrals
 Nurses
(Chiplaskey, 2009)
 Nurses not educated to offer quality end-of-life care.
 Nurses report they are afraid of speeding up death.
When Should We Talk About Hospice?
When is the right time?
Now – Now – Now - Now
Talk about it before its needed
Why Should I talk about it?
 If we do not talk about death or hospice we risk losing the
opportunity to help someone finish their final tasks of life
•Completion of worldly affairs
•Sense of completion
in relationships
•Sense of meaning about
one’s individual life
•Experience love of self
•Experience love of others
•Acceptance of finality of life
•Sense of new self
beyond personal loss
•Sense of meaning about life
•Surrender to the transcendent,
to the unknown
• Won’t it diminish their hope for recovery?
• Gaining meaningful life closure is worth it
(Waldrop, Meeker, 2014).
How to Talk About Hospice
Help for Physicians - S.P.I.K.E.S.
 S etting, listening Skills
 Environment and knowledge of prognosis
 P atient’s Perception
 Ask them what they know and what is most important
 I nvite patient to share Information
 Is it OK if I talk about hospice?
 Knowledge transmission
 What does hospice do
 E xplore Emotions and Empathize
 Validate their feelings
 Summarize & Strategize
 Can you tell me what you understand.
 I think hospice would be a helpful thing for you
(Talebreza, 2014)
Advanced Directives
 Can Advanced Directives start the conversation?
 Advanced directives are the perfect place to start not only the
conversation with your patient but to change our entire culture of
“Death Avoidance”.
 In a survey of 7,900 people, only 26% had an advance directive
(NHPCO , 2013)
 Are advanced directives associated with better hospice
 Patients with advanced directives spent more time in
hospice than average
 They were more likely to die in their preferred setting.
(Ache, Harold, 2014)
 Watson’s nursing theory of human caring
(Chantal, n.d.)
 Communication and a trusting nurse-patient relationship
 Patient gains a greater degree of harmony within the mind, body,
and soul
 Creates a healing environment (physical as well as non-physical)
 Debbie Messer Zlatin’s Life Themes Psychology theory
 Focus on how the dying person interprets his/her own reality as
opposed to the observer.
 She studied Life Themes: by interviewing dying people. A dying
person who had integrated life themes, were able to keep a sense of
who they are and what life meant.
 Caregiver s who are informed of the dying person's life themes are
more helpful to the dying person
(Jennings, n.d.)
ANA Standards
 Standard 5. Implementation
 A registered nurse in a nursing role specialty fosters
organizational systems that support
implementation of the plan.
 Standard 11. Collaboration
 Partners with others to effect change and generate
positive outcomes though knowledge of the patient
or situation.
 Standard 12. Ethics
 Delivers care in a manner that preserves and
protects patient autonomy, dignity, and rights.
(American Nursing Association, 2004)
Quality and Safety Education for
Nurses (QSEN)
The goal of QSEN is to prepare and educate nurses. They
provide resources to develop the knowledge, attitude,
skills, and overall competence of nurses.
six focus areas
 Patient centered care
 Teamwork and collaboration
 Evidenced base practice
 Quality improvement
 Safety
 Informatics
QSEN - Safety
Mindfulness as both a means of self-care for the
caregiver and a doorway to empathy In patient care
(QSEN, 2014)
The hospice nurse has all the same stressor including a
lack of time that create in inability to job to their
Being mindful to use coping strategies like a team
approach can make empathy available for patients.
Shoshannah, S. (2012)
 Start the conversation about death and advanced
directives in your personal life
 How can we talk to our patients if we can’t talk to our
 RN’s should obtain education about end of life care
and communication skills
 Dispel myths about hospice
 starve or hasten death
 To provide help to the community, we must continue
to educate on the culture of dying. What is a good
 Ache, K., Harrold, J., Harris, P., dougherty, M., casarett, D., (2014) Are advanced
directives associated with better hospice care? Journal of Geriatric Society, 62(6):
1091-1096. DOI: 10.111/jgs.12851
Alonso-Babarro, A., Astray-Mochales, J., Domínguez-Berjón, F., Gènova-Maleras,
R., Bruera, E., Díaz-Mayordomo, A., Cortes, C. (2012). The association between inpatient death, utilization of hospital resources and availability of palliative home
care for cancer patients. Palliative Medicine, 27/68 DOI: 10.1177/0269216312442973.
Retrieved from:
American Nurses Association . (2010). Scope and standards of nursing practice,
second ed. Washington, DC: American Nurses Publishing
Breitkopf, C., Stephens, E., Jatoi, A. (2013). Hospice in end-of-life patients with
cancer: does it lead to changes in nonhospice health care utilization after stopping
cancer treatment. American Journal of Hospice and Palliative Medicine. Doi:
10.1177/1049909113488927. Retrieved from http:/
Chantal, C., (n.d.) A pragmatic view of JeanWatson’s caring theory. International
Association of Human Caring. Retrieved from:
 Chiplaskey, L. (2009). End-of-life care: Are nurses educationally prepared? Journal
of Nursing. Retrieved from:
Hospice Association of America, (2010) Hospice facts and statistics. Retrieved
Hospice Foundation of America, (nd).What is hospice? Retrieved from:
Jennings, B., Gemmill, C., Bohman, B., Lamb, K. (n.d.). Kubler-Ross and other
approaches. University of Kentuky. Retrieved from:
National Hospice and Palliative Care Organization, NHPCO (2010). Preamble and
philosophy. Retrieved from:
National Hospice and Palliative Care Organization, NHPCO, (2010). History of
hospice care. Retrieved from:
National Hospice Organization, (2014). Hospice Eligibility Requirements. Retrieved
 National Hospice Organization, NHPCO (2013). New study on advance directives.
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Quality and Safety Education for Nurses. (2014). Pre-licensure KSAS. Nursing
Special Issue: Quality and Safety Education. Retrieved from
Sheehan, D., Forman, W., Kitzes, J. (2003). Hospice and Palliative Care: Concepts
and Practice. Sudbury, Ma: Publisher: Jones &Bartlet
Shoshannah, S., Walton, J., (2012). Caring for self: The challenges of hospice
nursing. Journal of Hospice & Palliative Nursing. DOI:
10.1097/NJH.0b013e31825c1485. Retrieved from:
Talebreza, S.,Wildera, E., (2014). The hospice referral. American Family Physician.
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Whittington, F. (2011). Denying and defying death: The culture of dying in 21st
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