Course Materials & Disclosure...2 Common Hospice Pulmonary Diagnoses ICD-9 Diagnosis 496.0 COPD, Not...

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Pulmonary Disease:Disease Trajectory and Hospice

Eligibility

Terri L. Maxwell PhD, APRN

VP, Strategic Initiatives

Weatherbee Resources &

Hospice Education Network Inc.

Course Materials &

Disclosure

� Course materials including handout(s) and

conflict of interest disclosure statement are

available to download with this course.

� This presentation is for educational and

informational purposes only. It is not

intended to provide legal, technical or other

professional services or advice.

Learning Objectives� List the stages and understand the clinical course of

pulmonary disease

� Identify “secondary” and “comorbid” conditions

commonly associated with pulmonary disease� Recognize the body structure(s) and body function(s)

related to pulmonary disease

� Recognize activity/participation and environmental components related to pulmonary disease

� Describe clinical documentation that supports medical

necessity and substantiates hospice eligibility for

patients with pulmonary disease

Hospice Education Network - Disease-Specific Hospice Eligibility & Documentation Series - Pulmonary Disease

Hospice Education Network (c) 2013

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Common Hospice Pulmonary

Diagnoses

ICD-9 Diagnosis

496.0 COPD, Not Otherwise

Specified

492.0 Emphysema

491.21 Obstructive Chronic

Bronchitis

515.0 Post Inflammatory

Pulmonary Fibrosis

518.8 Acute Respiratory Failure

ICF

Structure Function

Activity Participation

Environment

Guidelines for Hospice

Eligibility

LCD for Cardiopulmonary Conditions

(L31540)



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Cardiopulmonary Conditions LCD

� Identify specific structural/functional

impairments together with relevant

limitations that serve as the basis for

palliative care interventions and care

planning.

Body Structure – The Lungs

COPD

Emphysema

� Alveoli are destroyed. Walls become

inflamed & damaged.

� Elasticity is lost; pockets of dead air form.

� Airways narrow, air is trapped making

breathing out more difficult.

� The ability to breathe is affected in the

later stages of the disease.

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COPD

Bronchitis

� Bronchi (the main air passages to the lungs) become inflamed, usually as a result of viral or bacterial infection.

� Symptoms include coughing, shortness of breath, wheezing, and fatigue.

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Restrictive Pulmonary Disease

� Results from scarring or thickening of lung tissue. Lungs unable to expand – patient unable to breathe in.

� Symptoms include:

� Shortness of breath

� Chronic dry cough

� Fatigue

� Anorexia, weight loss

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Secondary Conditions associated with

Pulmonary Fibrosis

� Hypoxia can lead to pulmonary

hypertension, which can lead to right

sided heart failure.

� Pulmonary fibrosis increases the risk of

pulmonary embolism.



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Focus on COPD

Chronic Obstructive Pulmonary

Disease (COPD)

� Respiratory disorder characterized by

chronic airway obstruction and lung

hyperinflation

� 3rd leading cause of death in the US

�More women than men die of COPD

� 8.3% of hospice admissions (NHPCO

Facts and Figures, 2012)

Key Attributes of COPD

1. Airway obstruction

2. Not fully reversible

3. Progressive disease that generally

worsens over time, even with treatment

4. Abnormal inflammatory response

Celli BR et al. Eur Respir J. 2004;23:932-946.



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Factors Determining

COPD Severity

� Degree of symptoms

� Frequency and severity of exacerbations

� Presence of co-morbidities that can lead to complications

� General health status

� Number of medications needed to manage disease

� Severity of spirometric abnormality/airflow limitation

COPD Severity

Severity of airflow

obstruction

FEV1 % Predicted

Mild 50-80%

Moderate 30-40%

Severe <30%

Spirometry is the gold standard for

diagnosing COPD; severity is

measured by FEV1

Spirometry:

Normal vs. COPD



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Natural History of COPD

FEV1 <70- dyspnea with

exercise

�

FEV1 <45-

Exacerbations/hospitalizatio

ns/dyspnea with ADLs

�

FEV1<30- Systemic

effects/dyspnea at

rest/respiratory failure

COPD and Co-morbids

Common co-morbids:

• Cardiovascular disease

• Lung cancer

• Osteoporosis

• Musculoskeletal

disorders

• Depression/anxiety

• Obesity/type II diabetes

Functional Impairments inPulmonary Disease

� Cough and abnormal

breath sounds

� Fatigue, weakness

� Loss of appetite

� Shortness of breath

following activity or lying

down

� Swollen feet and ankles

� Weight loss

� Shortness of breath,

dizziness or a choking

sensation, accompanying

chest pain

� Waking up from sleep

due to shortness of

breath when lying down

(Orthopnea)

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Systemic Effects of COPD

� Peptic ulceration

� Lung infections/lung cancer

� Weight loss/muscle wasting and weakness

� Hypoxemia and rising CO2 levels

� Pulmonary hypertension that may progress to

right ventricular hypertrophy and cor pulmonale

(right-sided heart failure)

� Osteoporosis

� Depression

Acute COPD Exacerbation

� Definition: Sustained worsening of symptoms from

patient’s usual condition; acute in onset

� Symptoms

� Increased shortness of breath

� Increased sputum production and/or increase in

purulence

� Increase cough

� Increased wheeze/chest tightness

� Decreased exercise tolerance

� Increased fatigue

� Altered mental statusNICE GUIDELINES 2004

IV: Very SevereIII: SevereII: ModerateI: Mild

Therapy at Each Stage of COPD

• FEV1/FVC < 70%

• FEV1 > 80% predicted

• FEV1/FVC < 70%

• 50% < FEV1 <

80%predicted

• FEV1/FVC < 70%

• 30% < FEV1 < 50% predicted

• FEV1/FVC < 70%

• FEV1 < 30%

predictedor FEV1 < 50% predicted plus

chronic respiratory failure

Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation

Add inhaled glucocorticosteroids if repeated exacerbations

Active reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator (when needed)

Add long term oxygenif chronic respiratory failure. Consider

surgical treatments

Adapted from GOLD Guidelines.

http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=

1&intId=989



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Management of Stage IV: Very

Severe COPD

Characteristics Recommended

Treatment• FEV1/FVC < 70%

• FEV1 < 30%

predicted or FEV1

< 50% predicted plus

chronic respiratory

failure

• Short-acting bronchodilator as needed

• Regular treatment with one or more LA bronchodilators

• Inhaled glucocorticosteroids if repeated exacerbations

• Treat complications

• Rehabilitation

• Long-term 02 therapy if respiratory failure

• Consider surgical options

Adapted from GOLD

Guidelines, 2007

Advanced COPD Management

� Long-acting and short-acting

bronchodilators (albuterol)

� Anticholinergics (ipatropium bromide or

tiotropium)

� Methylxanthines (theophylline)

� Combination inhaled therapies

(formoterol/budesonide)

� Inhaled corticosteroids- note: long term oral

steroids are not recommended however, 7-10

day course of prednisone may be helpful for

exacerbationsAdapted from GOLD Standards, 2007

Management of Advanced

COPD (cont’d)

�Antibiotics – reserved to treat infections; do not use prophylactically

�Opioids – oral and parenteral (not nebulized) to treat dyspnea

�Anxiolytics – helpful in managing anxiety associated with dyspnea

�Oxygen therapy – should be worn 15 hrs or > per day for greatest benefit



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End of Life Issues

�Prognosis difficult to predict

�Frequent exacerbations requiring trips

to the ED and/or hospitalizations

�Patients/family members frequently do

not comprehend the terminal nature of

the illness

�Lack of communication and

advanced care planning

� Isolation/depression/anxiety

Signs that Patient Requires

Palliative Care

� FEV1 < 30% predicted

� History of 2 or more exacerbations in past

year

� Frequent hospitalizations

� Progressive shortening of intervals

between admissions

� Limited improvement after hospitalization

Supporting

Indicators

• Declining functional

status/homebound

• Presence of co-

morbidities such as heart

failure or diabetes

• On maximum therapy and

dependence on oxygen

• Disabling dyspnea at rest.



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Establishing, Evaluating,

and Explaining

Eligibility Based upon Burden of Illness in COPD

Assessing and Documenting

Disease Burden in COPD

� Sustained tachypnea (RR>30

breaths/min)

� Sustained tachycardia (RR>100

beats/min)

� O2 saturation <88% on room air or

patient’s usual supplemental oxygen

� Hypotension <100mm Hg or 20% lower

than patient’s usual

� Severe impairment of ADLs



� Inability to speak in full sentences

� Sustained use of accessory muscles of

respiration at rest

� Decreased ability to eat or sleep due to

respiratory distress

� Repeated lung infections/courses of

antibiotic therapy

� Hemoptysis/increased sputum

production/cough



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� Sustained increase in

patient’s usual degree of

dyspnea

� Medication changes-

addition or titration of

opioids, anxiolytics, etc

� Altered mental status-

lethargy, confusion

� Increased caregiver

stress/burden

Activities and Participation

� Learning & applying knowledge

� General tasks and demands

� Communication

� Mobility

� Self-care

� Domestic life

� Interpersonal interactions and relationships

� Major life areas

� Community, social & civic life

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ADL Documentation

Describe:

� How much caregiver support?

• None

• Minimal

• Moderate

• Total

� Time to completion of tasks



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Environmental Factors

� Products and technology

� Natural environment and human-made

changes to environment

� Support and relationships

� Attitudes

� Services, systems and policies

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Case Example:Pulmonary Disease

Referral #1: COPD

Mr. Smith

� Age: 76

� DX: COPD

� Residence: Home

� PCG: Wife

� PTA: 56 yr smoking

history; 5’9” 120 lbs,

BMI 17.7%

� Secondary

conditions: dyspnea,

cough, cachexia

� Co-morbid condition:

hypertension



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Measurable Data Points

Pt: Mr. Smith DX: COPD SOC: 9/20/12

MEASURE PTA 9/20/12

Weight / BMI (5’9”) 140 120 / 17.7%

KPS/PPS - 50%

NYHA or FAST - -

ADL Dependency - Amb, transfer, dressing

and bathing

Skin - -

Infection Pneumonia -

Oxygen PRN 3L cont / 90%

Admission Note

� S – Pt reports, “I can’t do anything anymore

and I’m totally exhausted all of the time. I can’t

catch my breath, even when I’m sitting doing

nothing.”

� O – Using accessory muscles & purse-lipped

breathing; push of speech noted; dyspnea @

rest; amb X 50 feet w/o rest 2 months ago; now

rests 5-10 min after only 10 feet; uses W/C with

PCG assist to maneuver in house (too weak to

self-propel); O2 @ 3L via NC; sat = 88% RAR

Admission Note, Cont’d.

� Admitted with COPD

� Structural and functional limitations: � Impaired respiratory function: dyspnea at

rest, push of speech, purse-lipped breathing

� Oxygen dependent; O2 sat 88%� KPS 50 & 4/6 ADL dependency� Impaired mobility

� Weight loss



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ICF Domains – COPDBody

Function

Body

Structure

Activity

Impairment

Participation

Impairment

Environmental

Factors

Dyspnea

with activity

Lungs Marked limitation

of physical

activity, unable to

propel

wheelchair

Essentially

homebound

Handicap

accessible

BR- Bedside

commode,

wc, O2

equipment

Fatigue/wea

kness

Dependent with

all ADLs

Loss of interest

in leisure

activities r/t

fatigue

Attentive

grandson

Favorite dog

Wheezing SOB inhibits

meaningful

interactions

Dyspnea with

conversations

24 hr PCG

Bipap

machine/

nebulizers


� Secondary conditions:

� Pneumonia (onset, type & treatment)

� Extreme fatigue (AEBR)

� Productive cough (describe cough, treatment, response, etc.)

� Dyspnea with poor response to medication (describe)

� Oxygen-dependent (flow, pulse ox, etc.)


� PMH:

� Increasing physician/ER visits and hospitalization for recurrent infections

�Pneumonia w/respiratory failure (6/28/12)

� Supporting documentation: unintentional >10% weight loss over past 6 mos.

� Fully meets Cardiopulmonary LCD guideline



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COPD Recertification

Documentation Example

“Patient is now completely bed-bound and

having new episodes of urinary incontinence.

Caregiver providing maximal assist with all

ADLs. Pt now severely dyspneic with minimal

activity, including trying to speak. Sleeping on

avg 18/24 hrs per day. PO intake reduced due

to coughing/choking episodes. Using MSO4 q 4

ATC with moderate relief”.

Conclusion� COPD is the 4th leading non-cancer

diagnosis in hospice

� Although irreversible and progressive,

COPD prognosis is difficult to predict

� Hospice eligibility and recertification is

based on the description of effects of

COPD on the structural, functional, activity,

participation and environmental domains,

plus documentation of secondary and co-

morbid conditions.

References

1. Global Initiative for Chronic Obstructive Lung

Disease (GOLD). Global Strategy for the

Diagnosis, Management, and Prevention of

Chronic Obstructive Pulmonary Disease (2007).

www.goldcopd.com

2. Poole, PJ, Veale, AG, Black, PN. Am J Respir Crit

Care Med 1998: 157: 1877-80.

3. International Classification of Functioning,

Disability and Health; World Health

Organization, 2001

4. NHPCO Facts and Figures, Nov. 2012



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Course Evaluation & Post-

Test

Thank you for viewing this course on the

Hospice Education Network.

To conclude this course and to obtain a

certificate of completion, you must finish the

evaluation and post-test.

Thank You!

Terri Maxwell PhD, APRNVP, Strategic Initiatives

Weatherbee Resources Inc. & Hospice Education Network

[email protected]



Course Materials & Disclosure...2 Common Hospice Pulmonary Diagnoses ICD-9 Diagnosis 496.0 COPD, Not...

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