For your consideration
Hospice Caring for Veterans & Their Families
As of 2017 there were 18.2 million military veterans representing approximately 8% of the US population. 91% of these veterans are male but the number of female veterans is on the rise. Veterans from World War II, the Korean War, and the Vietnam era account for 45% of the total veteran population and are all over 55 years old.
Veterans from the wars in Iraq and Afghanistan increase each year. These veterans make up approximately 25% of the veteran population.
Often veterans at end of life have unique issues that do not manifest in non-veteran patients. Veterans and their families may require a specialized approach to end of life care that addresses those unique issues. Over the past 15 years many hospices have developed programs and approaches that specifically address the unique needs of veterans and their families.
Unfortunately, veterans and military families often do not voluntarily report their military service at the time of admission to hospice. In 2015, the American Medical Association updated its recommendations for social history taking to include military history and veteran status. In addition, the American Academy of Nursing has designed the “Have You Ever Served? Initiative” to encourage health and mental health professionals to ask their patients about military service and related areas of concern. This program provides pocket cards, posters, and resource links for professionals working with veterans and their families.
Recommended questions for intake include:
- Have you or has someone close to you ever served in the military?
- When did you serve?
- What did you do while you were in the military?
- Were you assigned to a hostile or combative area?
- Did you experience enemy fire, see combat, or witness casualties?
- Were you wounded, injured, or hospitalized?
- Did you participate in any experimental projects or tests?
- Were you exposed to noise, chemicals, gases, demolition of munitions, pesticides, or other hazardous substances?
Potential Issues:
- Post-traumatic stress disorder (PTSD)
- Traumatic brain injury (TBI)
- Depression
- Substance abuse
- Military sexual trauma
- Domestic violence
- Intermittent explosive disorder
Learn more:
https://www.nursingoutlook.org/article/S0029-6554(13)00145-0/fulltext
revisited
Ketamine for Depression
The U.S. Food and Drug Administration, in March 2019, approved Spravato (esketamine) nasal spray, in conjunction with an oral antidepressant, for the treatment of depression in adults who have tried other antidepressant medicines but have not benefited from them (treatment-resistant depression). According to Tiffany Farchione, MD, acting director of the Division of Psychiatry Products in the FDA’s Center for Drug Evaluation and Research, “Because of safety concerns, the drug will only be available through a restricted distribution system and it must be administered in a certified medical office where the health care provider can monitor the patient.”
Treating patients with treatment-resistant depression with Spravato is done in conjunction with an oral antidepressant. Spravato is administered under the direct supervision of a health care provider and the patient monitored for adverse effects for at least 2 hours following administration. For detailed dosing protocols see link below.
https://reference.medscape.com/drug/spravato-esketamine-intranasal-1000325
Spravato is available as a 28mg dose pack. Depending on treatment protocol chosen, cost varies from $590 to $885 per treatment session.
The most common side effects experienced by patients treated with Spravato in the clinical trials were disassociation, dizziness, nausea, sedation, vertigo, decreased feeling, or sensitivity (hypoesthesia), anxiety, lethargy, increased blood pressure, vomiting and feeling drunk. For more detailed information follow the links listed below.
Although it would be rare for a hospice to treat a patient with Spravato nevertheless there may be that rare occasion where a patient has treatment-resistant depression and a short course of Spravato may be considered.
The use of ketamine IV for treatment of major depressive disorder (MDD) and bipolar depression (BD) has been studied in some small trials but has not gained FDA approval. However, a literature review in May 2019 by Drug Design, Development and Therapy found 417 articles mentioning ketamine and depression that they included. This review shows, in 14 publications, that ketamine provides a rapid and robust antidepressant effect with an onset of 40 mins after a single IV infusion in MDD and BD with a maximum efficacy at 24-hr post-infusion. This effect on depression is however transient and disappears in 1–2 weeks post-infusion. As more research is conducted the use of IV ketamine for the treatment of MDD and BD may prove to be a safe, effective, and inexpensive, short-term treatment for hospice patients who experience this level of depression at end of life.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717708/#CIT0044
regulatory Center
Clarifications for the Addendum as a Condition of Payment
Medical Review of the Addendum
- In the final rule, CMS stated that the addendum is not submitted with claims, as the election statement itself is not submitted with the claim. The addendum is only submitted when the MAC does medical review, but only if the beneficiary (or representative) requested it.
Issues with the Beneficiary or Representative Signature
- Addendum provided in person: In the FY 2021 hospice final rule, CMS stated that the beneficiary signature is an acknowledgement of receipt of the addendum, and this means that the beneficiary would sign the addendum when the hospice provides it, in writing, to the beneficiary (or representative).
- Addendum mailed or emailed: While we [CMS] believe that in most circumstances, the hospice would be furnishing the addendum in-person, we [CMS] recognize there may be those scenarios in which the addendum is mailed or e-mailed to the beneficiary ( or representative), meaning the actual provision of the addendum by the hospice and the receipt of the addendum by the beneficiary (or representative) may be a different date and where receipt of this document could be outside of the finalized timeframe.
- Goal of addendum: The goal is to ensure that this information is provided to the requesting beneficiary (or representative) in a timely fashion.
Hospice Processes for Addendum
- Documentation: We [CMS] did not finalize any prescriptive way in which hospices should document the provision of the addendum to allow hospices the latitude to establish a process to account for various scenarios.
- Signature Timeframes: We [CMS] also did not explicitly state that a beneficiary signature outside of the required time frame absolutely connotes that was the day the addendum was “provided” to the beneficiary.
- Hospice processes and documentation, including timeframes: As we [CMS] reiterated in the hospice final rules, hospices can develop their own process to document how discussions about the addendum occurred, when the beneficiary requested it and when it was furnished to the beneficiary.
- Documentation note for addendum provided through mail or e-mail: This could include documentation that shows that the addendum was provided via a means other than in-person, such as mail or e-mail and the date that the addendum was provided.
Updated
Drug Shortage List
These shortages are due either from manufacturing delays or shortage of raw ingredients. This is not an inclusive list, but the listed drugs may be used for hospice patients, especially in the inpatient setting. For a complete list of drugs on shortage follow this link:
https://www.drugs.com/drug-shortages/
The FDA is warning that there may be an increase in drug shortages due to the effect the coronavirus is having on raw products coming out of China and India used in the manufacturing of drugs.
New Additions:
Phenytoin (Injectable) – 9/25/2020
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About the Author
David Bougher
Senior VP of Regulatory Affairs
David is a seasoned veteran of the hospice world and an essential member of the Wise Hospice Options clinical team.
Education:
RN, BSN
Experience:
- Former hospice COO
- 20 Years of education & training experience
- 10 Years of experience at Wise Hospice Options
Connect
- (800) 856-9757 Ext: 203
- dbougher@wiseop.com
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Deanna Rice
Vice President
Clinical Services
drice@wiseop.com
(800) 856-9757:
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Tino Vilches
Senior Vice President
Clinical Services
tvilches@wiseop.com
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