Reading and Sharing My Notes (5)

Quality improvement is not a department or a single entity, but an ongoing conglomeration of approaches for improving cost reduction, efficiency, satisfaction scores, and overall outcomes. Research-based outcomes are now the standard for implementing changes within an organization. Bechmarking against successful organizations is another tool used in quality improvement, as well as surveys, root cause analysis, and a continual re-evaluation process.
Medicare is very particular as to what is covered under hospice care. The patient’s prognosis must be 6 months or less to live. Focus is not on heroic intervention or expensive testing for simple symptom management. Also, keep the goals of care in mind when considering orders, and continue to discuss the patient’s case at interdisciplinary meetings.

Reading and Sharing My Notes (4)

Veracity is the duty to tell the truth
Beneficence is the duty to act in a way that would best benefit the patient
Non-maleficence is the duty to do no harm
Justice is fairness for all
The HITECH Act’s modification to the HIPPA Privacy Rule, effective January 2018, grants access to a patient’s personal health information (PHI) 50 years after a patient has died.

Risk factors for complicated grief include a history of mental illness, substance abuse, previous loss, and sudden unexpected death. Medicare pays for bereavement counseling for up to 1 year after the patient’s death. Additional grief counseling would then be through a local support group. Studies have shown that men are less likely than women to openly express emotions or openly cry. This is felt to be a reflection of social norms for males having to show strength, and crying being perceived as a sign of weakness. Men often prefer to grieve alone or in private.
Portal hypertension often occurs in the presence of cirrhosis. Increased intrahepatic vascular resistance, and increased blood flow through the portal venous system, leads to the development of portosystemic collateral veins. With medium to large veins in the esophagus, the patient has up to a 30% chance of bleeding out within 2 years.

Hospice eligibility for dementia requires stage 7C or below according to the FAST scale (this means the patient is unable to ambulate without assistance, unable to dress or bathe without assistance, has urinary and fecal incontinence, and cognitive function has declined to the point where the patient can speak fewer than 6 words), as well as one or more qualifiers such as aspiration pneumonia. A decline in memory has to be substantiated by a demonstration of cognitive ability, such as verbal articulation. Inappropriate behavior such as hitting or acting out, does not neccessarily mean the patient has less than 6 months to live, nor do repeated UTIs.
Brain atrophy is part of normal aging, but the rate of atrophy is accelerated in individuals with Alzheimer’s disease. Studies have found patients with Alzheimer’s disease can have 3 to 4 % brain loss in a year, whereas loss of brain tissue secondary to atrophy with normal aging was < 1% a year.

Refractory or intractable symptoms are those that cannot be managed, even with agressive treatment. Often, for symptoms that multiple approaches have been used to manage symptoms and have failed, may require transferring the patient to an inpatient hospice facility.
Pain management in cancer patients is an important goal of care. Pain presents differently depending on the type of cancer. Usually, as the disease progresses, the patient increases, requiring more opioid management, as well as rotations to different opioids. Tumors can compress or stretch various organs, invade bone, or press on nerves. All of these require a different approach for pain management and should be investigated if the patient has a diagnosis of cancer.
Signs of pain in the cognitively impaired is demonstrated by facial expressions such as frowning or grimacing, vocalizations such as moaning, body movements such as guarding or rocking, changes in interpersonal interactions such as resisting care, becoming aggressive or withdrawn, and changes in activity patterns such as appetite or sleep changes. The combination of symptoms is more suggestive of pain, than depression or anxiety.
The PAINAD scale is used in advanced dementia by rating breathing, negative vocalization, facial expression, body language, and consolability.