Hospice of Kitsap County'sGuide for Physicians
Includes Medical Guidelines for Determining Prognosis
Hospice of Kitsap County is providing you with these guidelines as part of Hospice’s Physician Information
Service to serve as a reference and assist you in the care of your patients.
Our Interdisciplinary Team is available for consultation and assistance in providing the best home hospice
care for your patients. We are a Medicare and Medicaid certified, state-licensed agency with more than 20
years of home hospice care experience. We are a member agency of the National Hospice and Palliative Care
Organization, Washington State Hospice Organization, United Way of Kitsap County, and the Bainbridge
Island Foundation and have a reputation for excellence and high professional standards.
We thank you for trusting Hospice of Kitsap County to work with you in caring for your hospice-appropriate
Hospice care emphasizes the importance of the family-patient-doctor relationship and is a way of
insuring that individuals in the final stages of a life-limiting illness receive the full range of palliative
medical, nursing and supportive services.
Care for adult and pediatric patients with cancer or non-cancer diagnoses
Pain control and symptom management, including medications related to the Hospice diagnosis
Professional nursing and home health aide care
Social work, spiritual, and bereavement counseling
Trained volunteers for respite and bereavement support
When Part of the Individual Hospice Plan of Care:•
Short-term inpatient respite care at contracted facilities
Short-term inpatient care for symptom management at contracted hospitals and facilities
Dietary consultation, rehabilitative therapies (physical, occupational, speech), medical suppliesand durable medical equipment
The patient has a terminal illness with an approximate life-expectancy of six (6) months or less.**
The physician has informed the patient (and family, with patient’s permission) of the diagnosis and prognosis.*
The patient, family, and the physician agree to palliative (non-curative) care in the hospice program.*
A willing primary caregiver is available, or, with the assistance of the Hospice team, the patient is able to develop analternative plan for caregiving when no longer able to care for self.
* It is not necessary that the patient or the family accept the diagnosis or prognosis, nor is it necessary thatthe patient acknowledge that his/her illness is terminal. It is, however necessary that the patient be fullyinformed about the palliative nature of care, the diagnosis and prognosis.
** If the disease follows its usual course.
Preparing Patients for Hospice (From the National Hospice & Palliative Care Organization)“We are going to treat you aggressively, but a time may come when we will have to change our focus from cure to comfort.
My commitment to you is that I will be honest about what I am seeing.”(B. Baines, M.D. Family Practice)
“We must be honest and say, ‘I don’t have any more treatment that will cure your disease.’ Then we must be good physiciansand add, ‘I do have treatment that will ensure your comfort. I will be here for you.’(E. Anderson, M.D. Internal Medicine)
For many people, fear of the unknown is at least as great as fear of death itself. Presenting hospice as a medical option fortreating a terminal illness can help with many unknowns—“fear of uncontrollable pain, nausea, vomiting, embarrassmentand especially abandonment” that often accompany end-stage disease.
(Fletcher and Creagan)
Your Patients Will Be Reassured If You Can Say:
“As your physician, I will continue to see you and care for you”
“Our first priority is managing your symptoms”
“Services are available where you live”
“Your family / caregivers will also receive the support of the hospice team”
HOW ARE HOSPICE SERVICES FUNDED? / PHYSICIAN REIMBURSEMENT ISSUES
Services of the patient’s attending physician are billable
Congress has passed legislation creating a Hospice benefit
directly to Medicare/DSHS/Private Insurers, just as though
the patient were not on Hospice care.
Also, Washington State has implemented a hospice benefit
Physicians attending Medicare hospice patients may also
under DSHS. Participation in these certified hospice
bill for care plan oversight: G0065, for oversight services
programs is voluntary. To elect this kind of care, the patient
Consultative services related to the hospice diagnosis must
Be eligible for Medicare (Part A) hospital insurance or
be approved in advance by the Hospice Team.
Have his or her physician and the Hospice Medical
Director certify that he/she has a terminal illness.
Each person’s insurance policy differs. Hospice of Kitsap
Sign appropriate consent forms electing to receive
County will verify which benefits insurance covers. Most
hospice care in place of the standard Medicare/Medicaid
insurance policies, including HMO’s and PPO’s, include
Self Pay:The patient or family may pay directly. Financialconsideration is available.
The decision to maintain the patient in a palliative mode of care
(symptom management and pain control) is a joint decision
to be made by the patient, family, and physician.
Physical discomfort must be relieved before addressing all other forms of suffering: emotional, social, and spiritual.
At the time of the first visit to the home, the hospice nurse will perform an initial assessment for pain and/or level ofcomfort. A review of systems for symptom management is conducted with special emphasis on:
General Process for Pain Management:
Assess for multiple causes pain (physical, related or unrelated to primary diagnosis)
Treat each type of pain (use adjuvants for bone, neuropathic, visceral pain)
Reassess continuously, especially when pain remains uncontrolled
Hydrocodone/APAP 5/500 mg 1-2 tabs po q 4-6 hours
All new orders for strong opioids should be accompanied by:
Order for a stimulant laxative (e.g. senna)
Strongly consider an order for at least a few doses of an
An order for breakthrough pain medication if a long-
Equianalgesic conversion table: (abbreviated version)
For breakthrough pain:Oxycodone 5 - 10 mg
Morphine 10 - 15 mg 1 tab SL/po q 15 min prnLiq. Morphine 20 mg/cc 1/4 - 1 cc po/buccal q 1-2 hrs prn
Hospice Medications Often Used In Terminal Care:
Lorazepam (for agitation/anxiety/dyspnea):
Prochlorperazine (for nausea/vomiting):25 mg suppositories (#6)
Morphine (for pain/dyspnea) :10 mg SL tabs (#15)
Acetaminophen suppositories (for fever):650 mg (#12)
Hyoscyamine (Levsin) gtts. (for secretions):
(Transdermal Fentanyl Patch (DURAGESIC) 100 mcg
strength approximately = Morphine sulfate 30 mg po q
4 hours = Morphine sulfate 180 mg/24 hours)
GUIDELINES FOR PALLIATIVE CARE OF COMMON SYMPTOMS BY SYSTEMS
Physicians are welcome to request copies of our pre-printed order sheets.
Senna (Senokot) or Bisacodyl (Dulcolax) po 1 q day
Senna 4 tabs BID plus Lactulose 15 ml q day
Senna 4 tabs BID plus Lactulose 15 ml BID
Senna 4 tabs BID plus Lactulose 30 ml BID
DiarrheaClear liquids, plus one of the following:•
Loperamide tab po after each loose stool up to 8 doses qd
Diphenoxylate hydrochloride 5 mg po after each stool up to 8 doses per day
Prochlorperazine 10 mg po or25 mg suppository pr q 6 h prn
Promethazine 25 mg po or 25 mg suppository pr q 4 - 6h prn
Zolpidem (Ambien) 10 mg 1/2 - 1 tab po q HS prn
Atropine 0.5 mg IM/SQ/po q 4 - 6 hours prn
Hyoscyamine (Levsin) gtts, po/SL 1 - 2 gtts. prn
Oxybutynin (Ditropan) 5 - 10 mg po q 8 hrs prn
Nystatin suspension swish/swallow QID X 7 days
Clotrimazole troches 5 times a day x 7 days
Fluconazole 100 mg po 2 tabs first day; then 1 tab qd for 4 days
Miconazole/clotrimazole vaginal cream; one applicator at bedtime x 7 days
Oxygen at 1 - 3 1/m per nasal cannula prn
Lorazepam 1 mg tabs - 1 tab po q 6 hours prn
Hydrocortisone 1% cream topical 2 - 4 times a day prn
Occlusive opaque dressing prn (e.g. Tegaderm)
Because the care needs of a dying patient encompass more than medical treatment of a disease,the hospice team can be a valuable resource in dealing with complex end-of-life issues andextending the physician’s care. A Hospice referral can result in better care coordination, lesspanic, and more feelings that things have gone well and that the patient was well served.
Medical management at patient’s home.
24 hour availability of skilled care.
supervision. Assistance in locating other
securing supplies/equipment. Fullsupport to patient’s home.
and direction to hospice team.
Available for consultation (no cost) withattending physician on treatment plansand other issues.
anticipating and coping with crisisepisodes, the disease process, andwhen to call the doctor.
increases coping abilities of patients and
physician and the physician’s staff.
their time together. Hospice helpsfamilies prepare for the dying process.
Social worker assists patients and theirfamily members with locating availablecommunity services ( e.g. financialservices, Meals-On Wheels, etc.).
Establishes relationships with localagencies to provide patients and theirfamilies with low cost assistance, ifneeded. Spiritual caregivers providemulti-denominational spiritual support,if desired. Volunteer program forcompanionship, running errands, lighthouse work and short periods of respitecare. Bereavement programs forfamilies including adult grief and losssupport groups and specializedprograms for children and adolescents.
phone: (360) 415-6911 fax: (360) 415-6905
To make a referral to Hospice, please call the
Companions in Care Referral Center at (360) 792-6699.
Additive effect of rimonabant and citalopram on extracellular serotonin levels monitored with in vivo microdialysis in rat Ortega J.E.a,*, Gonzalez-Lira V.b, Horrillo I.a, Herrera-Marschitz M.b, aDepartment of Pharmacology, University of the Basque Country UPV/EHU and Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Spain; bMillenium Institute BNI and Programme of
La Busana (right side): David Uriel Hasson & Rivca Galante Alberto & Jaco Levy family Cohen family Menashe family (Grandmother of Fortune Soriano) Chilibee Turiel (daughter: Lea—Brussels--grandfather of Fortune & Bella Soriano) Dr. Mercado Hasson (lived upstairs & had medical clinic downstairs) Allegra Alhadeff (upstairs) (teacher of embroidery & French) Moshe Alhadeff childr