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State Hospital Patient Care Policy on Care at the End of Life
This policy statement is an example of a standing committee standards
and procedures for end-of-life care in an independent mental health institution.
Approval Signatures (dated):
Chief Operating Officer:
Medical Director:
Director of Nurses:
Director of Clinical & Rehabilitation Services:
(Other - specific to your institution):
Effective Date:
Renewal Date:
Review period:
Renewal Date:
Location:
Institution Policies and Procedure Manual
Purpose:
To establish a standard for care at the end-of-life for patients at (your institution
). This will include assessment of their illness, interventions and referral services
for palliative care and counseling for patients and/or families/guardians. This policy
will also establish a standard for staff development and training regarding end-of-
life care for patients with chronic mental illness.
This policy seeks to ensure that patients at (your institution) are treated with
respect, dignity and sensitivity through the final phase of their life. This includes
availability of services one would normally receive in the community in order to be
kept comfortable among familiar surroundings, family, friends and staff during his/her
final days.
(Your institution)'s administration supports the concept and philosophy of palliative
care to provide resources to persons with chronic mental illness and a terminal
illness, and to accommodate the person's end-of-life wishes, care and dignity by:
- Providing appropriate treatment for any primary or secondary symptoms, according
to the wishes of the patient or surrogate decision maker;
- Managing pain intensively aggressively and effectively;
- Respecting patient's values, religion and philosophy;
- Involving the patient, and when appropriate, the family and/or guardian, in all
aspects of care;
- Responding to the psychological, social, emotional, spiritual and cultural
concerns of the patient and family;
- Sensitively addressing such issues as autopsy or organ donation.
This policy is broad and flexible in accordance with the right to individualized end-
of-life care. Appropriate internal and external services needed to meet the needs of
individual patients and their families within the context of the patient's psychiatric
diagnosis, legal status, abilities, wishes and resources, will be determined on a
case-by-case basis.
Summary:
All (your institution) patients with a terminal illness will have the
opportunity to exercise their right to choose how to live out his/her final days with
support from (your institution) staff.
1. DEFINITIONS:
End-of-Life Care: Care provided at the end of life.
Terminal Illness: A debilitating condition which is medically progressive,
incurable and which can be expected to cause death.
Palliative Care: The comprehensive management of physical, psychological,
social, spiritual and existential needs of patients, in particular those with
incurable, progressive illnesses, by an interdisciplinary team, with the goal of
improving the quality of life. Palliative care affirms life and regards dying as a
natural process that is a profoundly personal experience for the individual and
family. Supportive care extends to family and those closest to the patient.
Hospice: As currently used in the United States, hospice refers to a specific,
programmatic model, reimbursed by Medicare, for delivering palliative care support
services, resources and medications to patients who are terminally ill. The majority
of hospice services are provided in the home but hospice services are also available
to patients who reside in institutions. Hospice care, therefore, constitutes a subset
of palliative care.
Family: For purposes of this policy, family is defined as relatives as well as
those with whom the patient has an established and close relationship, including
familiar caregivers and fellow patients.
2. BACKGROUND
Prior to the 1970's, terminally ill persons died in the hospital often alone and in
pain. Frequently, their desire to die in their own home among familiar people and
surroundings were not respected. With the development of palliative care and hospice,
persons today have services available to live out their life with respect, dignity,
free from pain, in their own nurturing environment that promotes quality of life until
the end. This approach to care focuses on the whole person - body, mind and spirit,
and those who comprise their "family" - surrounded by people and things they care
about in their own familiar environment while care and comfort is provided during a
terminal illness.
Patients at (your institution) recognize that (your institution) is their home and
staff that has cared for them is their significant support system. The standards for
end-of-life care at (your institution) will enable persons with chronic mental illness
to experience the same care and services available to persons in the community.
3. PERSONAL CHOICE FOR END-OF-LIFE CARE
A. Patients at (your institution) who have been diagnosed with a terminal
illness, regardless of diagnoses, will have their preferences for care at the end of
life respected and receive optimal individualized end-of-life care.
B. For the purpose of this policy, persons with a chronic mental illness and a
terminal disease will be afforded the option and choice to receive hospice services in
their own environment as their right as a patient, based on their eligibility subject
to the regulations of the Medicare Act and under (cite specific state regulation here
).
4. BENEFITS OF END-OF-LIFE CARE
This policy acknowledges the patient's right to informed care through the end of life
with an individualized plan of care involving the patient, family, guardian,
healthcare providers and other caregivers. The focus is to provide palliative care
including state-of-the-art pain and symptom management and psychosocial support, while
the person may remain in his/her own environment living his/her final days among
family and friends. This care allows respect for each individual's unique qualities,
values, culture, faith, spirituality and lifestyle with openness and acceptance of
their end-of-life requests. This applies whether the patient, or his/her surrogate,
chooses to continue intensive efforts to prolong life, or chooses to forgo further
life-extending care.
5. ROLE CLARIFICATION OF (YOUR INSTITUTION) STAFF AND HOSPICE CARE STAFF
The roles and services provided by psychiatry, primary care medicine, nursing, mental
health workers, pastoral service, social work and rehabilitation specialists will
remain unchanged. The role of the consulting outside hospice agency or affiliated
palliative care program regarding end-of-life care will be to provide advice on
services and recommendations of care to be delivered by existing (your institution)
staff.
6. END-OF-LIFE CARE COMMITTEE
A multi-disciplinary End-of-Life Care Committee will be established.
A. Reporting Mechanism
The End-of-Life Care Committee will report to the (Director/VP for Clinical Services).
B. Composition and Structure
The committee will include representation from psychiatry, primary care medicine,
nursing, mental health workers, pastoral service, social work and rehabilitation
services. Representatives will be expected to serve a minimum of two years with the
Chair rotating on an annual basis. Representatives from each discipline will be
replaced upon resignation.
C. Charge of the End-of-Life Committee
The committee will provide consultation in the development of further policies and
procedures pertaining to end-of-life care at (your institution).
The committee will meet quarterly to discuss up-dated end-of-life care information and
review current and/or potential hospice cases.
D. Responsibilities of Committee Members
Committee members will seek continuing education regarding end-of-life care and in
turn, provide advice, support and education to colleagues and hospital staff regarding
end-of-life care. This committee will act as a resource to facilitate a linkage
between internal and external end-of-life services for patients who are terminally
ill.
7. TRAINING AND STAFF DEVELOPMENT
Inservice training will be given by Committee Members, other identified experts, and
the hospice agency or affiliated palliative care program to (your institution) staff.
In addition, the hospice agency or affiliated palliative care program will provide
consultations on a case-by-case basis to ensure individualized care and services.
Yearly grand rounds will present end-of-life care updates in to all (your institution)
staff members.
8. PATIENT EDUCATION
Patients at (your institution) will be made aware of their options for end-of
-life care when they have been diagnosed with a terminal illness. Patients and their
families/guardians will be given all treatment and service options and be allowed time
to plan and participate in their end-of-life care.
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On this page:
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DRAFT Guidelines for End-of-Life Care of Patients with Serious Mental Illness
-
Work in Progress - Jim Hawkins, MD and Mary Ellen Foti, MD
These draft
guidelines are designed to aid psychiatrists/mental health
providers who care for seriously mentally ill patients provide
quality end-of-life care to their patients if/when they develop
terminal illnesses.
The guidelines advocate allowing these
patients to die in the setting most familiar to them, should they
choose to.
These settings include: state-run mental health
institutions (Institutions of Mental Disease -IMD's), transitional
or long-term care facilities, skilled nursing facilities, group
homes, supported housing, as well as other settings for people with
serious mental illness such as long-term VA units or Public Health
Hospitals, etc.
There are two sets of guidelines:
1. for
the care of the seriously mentally ill terminally ill person,
and
2. for the institution(s) providing the care.
We welcome your input.
You are invited to download
the guidelines for review and contact us with your
comments, suggestions, and questions.
See these draft guidelines in the Clinical Tools area of
this Web site.
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Funding hospice/palliative care in a state mental hospital or similar facility:
Information from CMS 10-2002 for MEDICARE
Please note: CMS has not addressed this formally in any manual guidance.
Medicare hospice regulations do not define the term "home". It is not uncommon for
individuals to "reside" in an assisted living facility, nursing home, or other more
institutional setting and receive hospice care. While the person is residing in the
facility and receiving hospice, Medicare would pay the hospice provider the
appropriate home care rate.
Contracting with a State psychiatric inpatient facility for the provision of
hospice services to patients who would remain a patient at the facility:
It is conceivable that an individual could "reside" in a psychiatric inpatient
facility and receive hospice care. If that were the case the following would apply:
1. the hospital stay is no longer a Medicare stay
2. the cores services must be provided by the hospice, and
3. the hospital has to agree to the peimacyprimacy of the hospice plan of treatment (
which takes into account the mental illness) and enter into a contractual agreement
with the hospice per 42 CFR 418.56, and
4. there is an appropriate process under which the patient or his/her representative
made the necessary election.
Funding hospice/palliative care in a state mental hospital or similar facility:
Information from CMS 10-2002 for MEDICAID
CMS has reported that the same ideology (as above, with respect to Medicare) would
apply to Medicaid. It is recommended that you consult with CMS directly as there is
no concrete guidance regarding this issue. We have learned that CMS has not been
asked about this issue previously and therefore has not created specific regulations
to apply to it.
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For more information regarding Medicare/Medicaid reimbursements, contact the Medicare
/Medicaid management division of CMS at
http://cms.hhs.gov
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This information is provided by the Massachusetts Department of Mental Health. End-of-Life Care for Persons with Serious Mental Illness is a multi-faceted project supported by a grant from Promoting Excellence In End-of-Life Care, A National Program Office of the Robert Wood Johnson Foundation. Visit the main Web site at www.promotingexcellence.org/mentalillness/
