Welcome to Q&A with Dr. K, a podcast by Mountain Pacific Quality Health, where we sit down with Dr. Doug Kuntzweiler and get your health questions answered. Because on Q&A with Dr. K, the doctor is always in. Hello, everyone, this is Beth Brown, your host, and I'm here as always with our very good friend, Dr. Kuntzweiler.
Hello.
Hi. Today's patient question comes from someone I happened to be talking with who wanted to ask about hospice care and really understanding what hospice is about, specifically, when do you decide it's time for hospice, and then understanding what Medicare will cover and
won't cover. So this person had a loved one in hospice, and they were confused about being told that they couldn't go to the emergency room, or get certain care that this loved one wanted or thought they needed, because it was quote outside of hospice care. So Dr. K, you've had experience caring for hospice patients, right, in your long career. So did you get these kinds of questions from folks when you cared for them?
Sure, and hospice is sort of nebulous. And I think most people don't have a really good idea of, of what it is. But it basically started becoming popular, I think, around the 1970s. And it's just
end of life care. And so if you have a person who has a fatal illness, and they decide that they are tired of treating it, tired and fighting it, you can still have care under hospice and hospice treats, you know, whatever symptoms you have, and helps you stay socialized and helps the family take care of the patient, it can address your spiritual concerns, every aspect of end of life care is covered by hospice. And when we think about well, who delivers this?
Well, there are nonprofit hospice associations, there are for-profit hospice associations, you have to look around in your community and see what's available. But it can be delivered in the hospital, it can be delivered in a nursing home, it can be delivered in the patient's own home.
And that was my mom's experience. We did hospice in the hospital, which I think it maybe can be trickier there or not, I'm not sure. But when we talk about this patient's question of what care you can get and what care you can't get, what does that mean?
I think people get confused, because they feel like if the doctor says you've only got six months to live, and we're gonna put you on hospice, then you have to stay at home, and you don't have any medication or any active treatment. And that's, that's not true. Medicare, you can always call and see what what is Medicare is going to pay for them, they often will pay for it in home care, or some skilled nursing care in home, or non-skilled help in the home, they will pay for medications.
Now, sometimes you will get into situations where if it's an active, say cancer treatment, they may say, well, that's really not what hospice is about. And so they may not pay for that. But they're always open to discussion, actually. And you can talk about what they will be willing and what they won't pay for, but in general, they will pay for everything except active treatment that is aimed at extending someone's
life. And sometimes there are gray areas and your primary caregiver can sometimes convince Medicare or whoever is paying for it to cover things that are maybe in a little bit of a gray area. And you can get other care if you need to go to the emergency room, that hospice doesn't stop at at your door, they can cover emergency stuff, especially if it has to do with comfort.
Yeah, that's great. And I think the biggest message there is if you don't understand, ask questions.
Yeah, absolutely. And your primary caregivers should know something about it. But there are also other resources. You can you can call any hospice providers in your community. And the other thing that people I think get confused about is, once you're on hospice, you don't have to stay on it. If you decide that there's a new development and you feel like maybe you want to start doing some more active treatment, again, you can always
go off of hospice. And to start on it your physician or your provider usually certifies that you have a condition that is likely to be fatal within the next six months. And so people think, well, six months is what I have to go back on active treatment. No, your doctor just has to certify again that, you know, we expected that that would be six months, but you know, they're still alive. And we expect that sometime within the next six months, then they
will die. So it's it's fairly fluid, but you have to talk to people and don't hesitate to ask questions.
People probably hear the term hospice, they hear palliative care, they hear comfort care, what's the differences between those or are they all kind of the same?
They're all similar. Palliative care is is strictly treating symptoms to make people as comfortable as possible. Hospice is really broader than that. And it doesn't mean if you have other chronic conditions, you don't stop treating those under hospice. You can still treat your high blood pressure, you can still treat your diabetes, chronic lung disease, you can still be on oxygen and do breathing treatments, and all of
that. Palliative care specifically addresses the very end of life care and keeping people comfortable.
Let's talk about caregivers. You've mentioned all the different settings where people might be able to get hospice, but a lot of people do get that care in their homes, and they have family or people who love them around them. What should they know?
Well, they should know that it really shouldn't be a team effort, taking care of somebody who's dying in your home is it's a monumental task. And people shouldn't be attempting to do that alone. So you know, you should put together a team of family members of friends, volunteers, and then the hospice team can come in and advise you as to what other resources there
are. If you are going to be the primary caregiver, you really need some respite and there are respite services available through hospice so that you can get away because it's, it takes a real toll on you physically and mentally and spiritually.
Yeah, that is so important. And people tend to neglect doing that, because they're more worried about the person who's sick than about themselves.
If you wear yourself out, then you can't be any good to anybody else. So really, it takes a team. And that's how you should think about it. What are my resources, who I know that I trust that can help and then put that together? And that's a reason to talk about hospitals earlier, so that you can do that. Most people are pleased with their hospice experience, but they almost universally say we wish we had done this sooner.
So you mentioned the breathing treatment, for example, for someone who has a chronic lung disease. Are there certain medications people can or cannot take once they've gone
Well, I talked about that a little bit on hospice? before, not so much. There are some things that are very specific, like cancer treatment drugs that hospice shies away from because their goal is to prolong life. And hospice is really not about so much prolonging life, it's about making life better in the final
stages. So there are some drugs that are that are designed just to prolong life and those who might not continue, treatments like radiation treatments, you might not necessarily but again, there's gray areas if the radiation is for comfort, so that you can swallow better or
Okay, that makes sense. Okay, so basically, you that kind of thing. need to stop treating the illness, and you're just trying to help the person be comfortable, anything that treats the illness. That's what you cross out, right? Okay, perfect. So morphine, and those kind of painkiller drugs, how do they come into play that they don't do anything to treat, they just make the person comfortable?
Right. That's part of the paliative care, whatever it takes to make people more comfortable. And sometimes that can look like active treatment. I mean, there are drugs that we think of as active treatment drugs, you know, and sometimes the patients themselves, negotiate this, you know, I had a hospice patient who had severe rheumatoid arthritis and was just tired of
being in pain all the time. And she got pneumonia and hospice were paid to treat the pneumonia, because dying of pneumonia is uncomfortable and not very pleasant. And she refused. She said, No. So we didn't treat it, we could have but we didn't, because that was her wish. Nothing is really written in stone when you're talking about hospice. Some things can be negotiated. And some things that you would think maybe wouldn't be paid for can be paid for.
Talking about morphine. Specifically, I know that some people are worried or have read, and I think it is partially true, but I just want your expertise on this, that morphine can expedite the dying process.
Yeah, but that's usually very, at the very end, morphine tends to depress your respiratory drive. And so if you give people enough morphine, they stop breathing, and that's how people die of overdoses as they just stopped breathing. But for people who say have cancer they have you know, severe pain, people's tolerance for morphine goes up pretty quickly and you wind up, you know, escalating the doses just to keep them comfortable.
The worry about well, I'm basically killing them is that's not really what happens.
Okay, good, because I do think that can be a person's concern. They want their loved one to be comfortable, but they also want to make sure it's happening naturally.
It's possible with the narcotic medications we have today, it's possible to titrate things very carefully and keep them comfortable and you're not necessarily ending their lives.
Okay, good. That's probably a relief for a lot of folks. So you talked about if we talked about, too, if you have questions, ask them. What questions should you ask for people who are sort of in that numb, like, I hear what you're saying, but I don't know what I should be doing? What are some questions that you can give them that they can have in their back pocket?
Well, I think the first thing is to talk to the patient and say, How do you feel about this? Are you ready to kind of stop struggling with active treatment, and just think about maximizing the time you have left, making that as pleasant as possible, because once they make that decision, then it's just a matter of, as I said, getting your team together, talking to your local hospice, seeing what services they have available? Well, I kind of neglected to mention the
VA also has hospice services. So if you have a veteran who has a terminal illness and is getting tired of fighting it, you should talk to the VA because they can provide respite services, and they can provide hospice services.
And you can talk about a care plan with the hospice team as well, right?
Right, absolutely. That's what they will do. You know, and they are used to doing this. So they will see what resources you have. And they will advise you what resources the hospice has, and together and and with the patient, you will come up with a plan of what you're going to do. And it makes people feel a lot
better. If you know you've you've thought it out ahead of time and have a plan, you know, if you need to go to the hospital at the end, because it's just too difficult to keep them comfortable at home anymore. That's totally appropriate. And that's covered. So just knowing ahead of time what the plan is how things are going to go is a big relief. I've seen so many people where they didn't go through this and push came to shove and the patient was dying. You know, they come rushing into the ER
and that's a chaotic scene. And it's not good for anybody, particularly the patient, but not good for the family either. So talking about it early on getting a plan, everything is much better.
So we talked about respite care. What about once the person has passed, because obviously that's what we're preparing for here. But grief and kind of dealing with that death.
Yeah, most hospices incorporate some, either psychologists or clergy that are trained in grief counseling, and that's that's a part of hospice is helping the family grieve. And, again, planning for that ahead of time also provides quite a bit of relief.
Hopefully we've covered everything that the person asked about, but just in case somebody needs more information, as always, let's end with some great resources for folks.
Well, it turns out, there's a national hospice and palliative care Organization. So that's where I would go first. And then I would talk to there may be more than one hospice available in your community. So I'd go and talk to them. And most hospices are affiliated with a physician, often as a primary care physician. Those people are very
knowledgeable. So even if that's not, you know, your loved one's primary caregiver, they will be involved with with the hospice association, so it's good to talk to them and see what they recommend.
Everybody's different. So sometimes just talking about this specific situation is your best bet. Yeah. All right, perfect. But we will put those resources at the bottom of our episode for folks who would like to learn more about hospice or understanding hospice care. And thank you, Dr. K. Thank you. All right. And thank you for listening. And if you have a question for Dr. K, please email us at QandAwithDrK@mpqhf.org. And that email address will be with this episode as well. Please email us
your questions. The doctor is always in.