Speaker 1: 0:01

Welcome to the Healthy Matters podcast with Dr. David Hilden , primary care physician and acute care hospitalist at Hennepin Healthcare in downtown Minneapolis, where we cover the latest in health, healthcare and what matters to you. And now here's our host, Dr. David Hilden.

Speaker 2: 0:19

Hey everybody, and welcome to episode 22 of the podcast. I am your host, David Hilden . And today we are gonna be talking about a really important topic that being hospice and what to expect at end of life. To help me out, I have a physician colleague of mine, Dr. Miriam Anmar . She is the director of the Division of Geriatric Medicine at Hennepin Healthcare here in downtown Minneapolis, and she's a hospice physician with Acumen, which is a leading hospice organization that she is a part of. So thank you for being here.

Speaker 3: 0:49

Glad to be here. Thank you for inviting me.

Speaker 2: 0:51

Okay. So Dr . Anmar , tell us, first of all, if you would, what is hospice care? Just the basics of when you're explaining somebody the first time. What is hospice?

Speaker 3: 0:59

Yeah, I'd like to kind of talk about hospice and how it differs from kind of palliative care. And if you think about like the trajectory of a chronic life-threatening illness, palliative care can really be involved at any point in that trajectory. Um, it helps to improve that overall quality of life and, you know, navigate the difficult circumstances. Hospice on the other hand, that comes into play when there's a more limited time of life expectancy around six months, and the focus shifts from a curative intent to managing more of the symptoms and the circumstances at the end of life. So you think about hospice when cure is no longer possible, or the burdens of treatment outweigh the benefits. So

Speaker 2: 1:46

You are, as I said earlier, the director of geriatric medicine at Hennepin, and I know what that is. But just while we're doing definitions, what does a geriatrician do?

Speaker 3: 1:55

We care for older adults. Our specialty is caring for older adults and helping people navigate aging. So, you know, we receive patients from 65 and older. Our clinic actually does 62 and older. And from the robust elderly to the frail elderly, we treat and manage that whole spectrum and either promote healthy aging or help with chronic disease management and illness and make them as functional and try to improve the quality of life as much as possible.

Speaker 2: 2:26

Yeah, thank you for that distinction, because I'm, I'm so well aware of what your division does. It's in my Department of Medicine at Hennepin, and I'm so impressed with all of the physicians, the researchers, the advanced practice providers in the geriatrics medicine division. So I just wanted to get that out there. Now, back to hospice. So it's been around a long time, people maybe have just a smattering of knowledge about what it is. Could you share with us what are some of the key principles of hospice care when somebody is considering getting these kinds of services? So

Speaker 3: 2:56

It's really a holistic support. We support the whole person, their physical, emotional, and spiritual needs. The principles include really focusing on pain and symptom management. You know, we wanna maintain that quality of life, but also that dignity. I think that's also kind of really important, like a team based approach with like kind of good communication and providing that really holistic support. Providing bereavement support is also a key principle.

Speaker 2: 3:25

Well , now what you just said there makes 100% sense to me in that wouldn't every single person want that at the end of their life? You

Speaker 3: 3:33

Know, we birth is a happy experience, we all plan for, right? But death is something we don't plan for. We don't talk about enough. Even early end of life decisions to talk to a physician are very difficult for a lot of people. And studies have shown that people who have enrolled in hospice, they are more likely to have their end of life wishes answered.

Speaker 2: 3:58

That's exactly what I would think we would want. So that was a good segue into my next question for you is what are some common misconceptions about what hospice care is? One of them might be, at least that I hear a lot, is, well , you're throwing in the towel, you're giving up on me.

Speaker 3: 4:12

Yeah. And hospice is number one. It's not for the dying. That's the common misconception that I'm, you know, like when you're in the , the active faith of dying, it's only kind of when you're enrolled in hospice, but hospice earlier on is actually more benefit for that , um, emotional and that support and that that hope actually shifts. You know, when you are not hoping for cure and when cure isn't always possible, but that hope is for dignity, for comfort, for peace, for family support to maybe be at your own house, to may maybe , um, be surrounded by family instead of having recurrent hospitalizations. You know, another misconception is I can't keep my own physician , um, which is not true. You can keep your own physician. We wanna maintain those lifelong relationships that you may have had , um, with family.

Speaker 2: 5:00

So it's not a place you go. Is that true? Hospice

Speaker 3: 5:03

Will come to you,

Speaker 2: 5:04

They come to you, they come to you because you said in your own home. I think some people have said, well, I don't wanna go somewhere to some facility. Now there are some of those, there are residential hospice where you can go and live, but most of the time that's not it, right?

Speaker 3: 5:16

No. They come to wherever you are. So if you're in your home and you're in a nursing home assisted living facility, the hospital will come to you, the nurses will come to you, the team will come to you and provide comfort for you know, where you are and support that.

Speaker 2: 5:29

Yeah, I hear that all the time. And , and , and then you , you tell someone that , no, you can live in your own bedroom or, or , or your own assisted living your own apartment. And the people, their eyes light up. They Oh , really? That they, they really like to hear that. Any other misconceptions that we haven't covered ? That it's not just for the last few days of dying. It's for emotional and spiritual part . You , your physicians can come to you, you can keep your physician. Could you just delve a little bit more into this concept of hospice isn't abandoning someone who is in the last several months of their life. We're not giving up. We are just shifting the focus of what we're doing. Could you say a little bit more about your experience with that? What does that mean?

Speaker 3: 6:09

I think a lot of family and patients notice a natural decline. And there's kind of an intuition that, you know, the body is shutting down, they're eating and drinking. It's less, the appetite decreases and there's, you know, more functional decline. And so sometimes when we try to push someone to focus on that curative intent, when their , their , their hope is just to be comfortable. You're actually not doing a service or a benefit to our family members or loved ones. And so I think really having that good communication conversation with your care team and your , um, patients and involving palliative care to really think about what is important to me or to my family member at this time and what is the kind of the reality of the situation. There's more focus on , um, you as a person and your comfort than just maybe ending up in the hospital, but you might not want to have your last six months in the hospital half the time. Yeah.

Speaker 2: 7:17

Yeah. I'm gonna shift a little bit about to the eligibility and sort of the timing of hospice, because a lot of people think, well , it's the last three days, it's time to get hospice. That's not it. Could you just walk us through what are the criteria for hospice care eligibility?

Speaker 3: 7:32

So Medicare is very specific disease criteria, which are very helpful for a specific, like, you know, cancer or dementia or end stage heart failure, end stage lung disease. But the overall principle is that infusion that you have like six months or less to live, decrease in the palliative performance scale, which indicates like your functional decline, increased dependency on your activities of daily living, like your eating, you know, you lose your , uh, ability to bathe or to toilet independently to shower independently. Weight loss, which is not really due to a reversible cause or it can be like a declining serum albumin,

Speaker 2: 8:09

A blood test. We get a protein. Yeah, yeah.

Speaker 3: 8:12

Um, difficulty swallowing, dysphagia, you know, aspiration, pneumonia, progressive like ulcers, skin ulcers can indicate lack of nutrition and indicate end of life especially, they're not healing. So

Speaker 2: 8:24

If a family member sees these things in their loved one, that's maybe some signs that it's saying and , but you also have to have a diagnosis, right? And then don't you have to get a , because I've done these, you have to get a physician or somebody to certify that you perhaps have less than six months to live. Although nobody's can predict that perfectly. But that has to be, that's the general rule, right?

Speaker 3: 8:44

Yeah. So the patient can call the hospice team directly or they can be referred to their hospice, and then the certifying hospice physician will determine their eligibility

Speaker 2: 8:54

Criteria. So I know it's really hard conversation for many people to have with their family members about end of life things, but when do you recommend that people, not in hospice, but just people in general , um, should start talking about their end of life wishes with their families? I've

Speaker 3: 9:11

Had patients with, like, I have a patient with Lewy body dementia, or a patient with a critical aortic stenosis. And we've had conversations when they were healthy. So when they were alert cognitively , um, intact , um, to some degree able to make their own decisions and really having the conversation early on and at every decline. Like if there's a hospitalization, there's an event, it's another good time to renew the conversation or where there's new information about your disease illness. So when my patient with critical AOR stenosis, she knew she did not want surgery. She knew she didn't want to be intubated if, if something happens

Speaker 2: 9:51

Too down your throat,

Speaker 3: 9:51

Right? And so when our dementia progressed and it became more severe , um, it was easier to have those conversations with those families on how we, you know, how we should proceed.

Speaker 2: 10:00

And it's not just in cancer patients, is it? Hospice isn't just, people also think that it's, well, I don't have cancer, you know, but you mentioned some other diseases, dementia, advanced heart failure, so it isn't just cancer.

Speaker 3: 10:11

So as a geriatrician, I , I'm mentioning these more 'cause I, I see , uh, more of my patients with , um, chronic lung disease or pulmonary disease or be a lot of dementia patients too, when your decisions kind of matter based on the cognitive and the functional, right?

Speaker 2: 10:27

So you have to have those conversations earlier. This is a little self-promotional plug here, but about 15 years ago, I was interviewed by the New York Times about this very topic and how the New York Times got my name here in the, in the frozen tundra of Minneapolis, I'm not quite sure, but it was an article about when do you have end of life conversations? And it was a bunch of cancer doctors who were very reticent to have conversations. And so people were dying without having had these conversations and they wanted some doctor to take the opposing view . So I was that guy. I don't know why. And I, I said we should have that conversation a lot earlier. Now that was about 15 years ago. I do feel a little vindicated because I hear that a lot from, from geriatricians palliative care folks , uh, people who are in hospice, that it's good to tell your family members well in advance, especially if you have something like dementia. Well, in anything, but for dementia, it's for sure because you can't make those decisions later.

Speaker 3: 11:23

Yeah. And decisions about feeding tube, you know ? Mm-Hmm . <affirmative> family feels so conflicted sometimes. Like , especially I , uh, I work at Good Sam , there's the high population of Huntington's patients. And, and often those families make their decision to talk about, no, I don't want a feeding tube at the end of my life. They're very certain about that. It helps families so much when they have that stage five , um, end stage and they're really declining in their appetite, increased dysphasia. So , um, I think it's a , um, service to have to your families to , and to yourself when you wanna minimize that suffering. Yeah. At the end of life.

Speaker 2: 11:57

And that's what most people want. It's just what is suffering. Um, and it's different, but for different people. I'm gonna shift a little bit about who's on the hospice care team. When you enroll in hospice, what kind of services are available and who's on that care team?

Speaker 3: 12:11

First having a nurse, and that's what patients love the most frequent nurse visits. And also , um, having that availability to call a nurse twenty four seven.

Speaker 2: 12:21

Shocking. It's never the doctor folks. And you know, I know this, when patients always say who , whenever we talk about care team, the number one person, and I will second, this is always the nurses. They're the heroes of medicine, to be honest. Okay. They , you , so you have a nurse available to you.

Speaker 3: 12:36

Yeah. And you know, I , when I see my patients on hospice, and it's , it's , it's really encouraging and heartwarming when they have like their chaplain visits and their music visits and they're really singing along, you see a completely different aspect of your patient when they're singing with a mu with

Speaker 2: 12:52

A , so a music person, a thera , a music therapist.

Speaker 3: 12:54

A music therapist, yeah. Um, those are kind of complimentary therapies and massage therapy for their back pain. I think my patients gonna shave, you know, they're like volunteers and things.

Speaker 2: 13:04

You don't think about

Speaker 3: 13:05

Things you don't think about know

Speaker 2: 13:06

That music and maybe getting shaved. Yeah . You know, you know, it makes you feel a little bit of dignity and then

Speaker 3: 13:11

Social work. And it's really hard as you decline, and especially if you're at home and you need increased help and services. So that social work will really help guide and help with placement or increased assistance at the end of life. And then I would add that , um, bereavement care is there for a year after the patient is deceased for the family. And so I think it's really a holistic patient and family care .

Speaker 2: 13:34

Mm . A year afterwards you get assistance with, with the grieving process. That's the kind of team, if you could do your dream team of, of your healthcare when you are in the last , uh, phases of your life here on earth. What a , that's the dream team you get. And you get a doctor in there too. <laugh> ? Yeah. Okay. We're talking with Dr. Miriam Anwar . She is the director of the geriatrics division at Hennepin Healthcare . And we're talking about hospice care. We're gonna continue our conversation right after a short break, so stick with us. We'll be right back

Speaker 4: 14:05

When Hennepin Healthcare says, we are here for life. They mean here for you, your life, and all that it brings. Hennepin Healthcare has a hospital, HCMC and a network of clinics both downtown and across the West metro. They provide all the primary care and specialty care you would expect to find, but did you know they also have services like acupuncture and chiropractic care available at many of their primary care clinics and at their integrative health clinic in downtown Minneapolis. Learn more@hennepinhealthcare.org. Hennepin Healthcare is here for you and here for life.

Speaker 2: 14:43

And we're back talking to Dr. Miriam Anwar about hospice care and end of life issues. So Dr . Anwar , what I'd like you to talk about, about, if you could, about what some of the positive impacts of hospice care are on patients and their families. And maybe you could even think of a , a patient that you've cared for or that you've been a part of , uh, to help illustrate that I

Speaker 3: 15:02

Had an elderly female with critical aortic stenosis. That's a

Speaker 2: 15:06

Heart valve problem. Yeah.

Speaker 3: 15:07

She also had dementia and she was very, and we had early life decisions that she did not want surgery and did not want intubation or aggressive care. So she came with her daughter with kind of like acute heart failure exacerbation that , you know, fluid in her lungs, a lot of edema, tried to manage her as an outpatient with diuretics, you know, to get the fluid off and , um, wasn't successful. So at that point we had that conversation that we have a life-threatening illness that's not really reversible, you know, in the absence of surgery, which she clearly was too, you know, old and frail and deconditioned for , and she was already on a palliative care approach to, you know, think about just being comfortable or, you know, we could hospitalize and get the fluid off. Um, which I thought was very reasonable too. And she was a very sparky and fun lady , um, very pleasantly , uh, demented and didn't have any symptoms. You know, she felt great, which

Speaker 2: 16:08

She wasn't like gasping for breath or something, or pain. That's what you get with aortic stenosis.

Speaker 3: 16:13

Yeah. So we felt , um, very, I felt it was very reasonable to hospitalize her to get the fluid off. And she actually survived for a year. Um , after that, a year later she was readmitted for atrial fibrillation. She had a, had a stroke. She was, you know, more confused and frail , um, at that point. And so I had that discussion again with the family about how to maybe focus the care now based on her decline, her recent hospitalization, increased confusion, increased frailty and deconditioning, and transition to a more comfort care and hospice approach. So we , she enrolled in hospice and for a a , a few months after it was very supportive to have managed her comfort and the pain and , um, therapy . How

Speaker 2: 16:58

Was her family through all this? Because again, you know, this patient has a heart valve problem. Yeah . Which is basically terminal. She's not gonna survive this. There's no way to fix this thing. Medications aren't gonna work forever, but still, that's not really in family's consciousness. What , what do you mean hospice? She's got a heart problem. How did you get the family to understand the situation? I guess no

Speaker 3: 17:17

Matter how much knowledge you have, I think the hospice workers really help ground you and as hospice physicians into the reality of the moment. Mm-Hmm . <affirmative> because , you know, when we are family, we are kind of more protective and it's very difficult. And to be in that reality of the moment, to see what's going on from the perspective of those who are really in tuned and experienced at the end of life, that's one of the benefits I think too, that helped this family being grounded in the reality of the moment and just having that support of the staff that , um, bereavement the poor , their spiritual care, that family care, and to see their loved one, you really be comfortable and peaceful and dignified at the end of life.

Speaker 2: 18:00

Yeah . And so that family experience, it sounds to me like the full range of hospice services, you know , in a condition that they maybe didn't know they were gonna have to do. You know, mom's getting confused. She has dementia, she's got this heart valve problem and what this comprehensive multidisciplinary team can do for you sounds just like a gift to me. It, it really does. So Maria , you can't talk about healthcare without talking about the money part of it. So how is hospice paid for? Is it covered by insurance? Is it covered by Medicare?

Speaker 3: 18:29

It's the Medicare benefit, a Medicare part a benefit. Um, if you have private insurance on Medicaid, it also covers hospice. So it provides that whole holistic support and that team at your place covered by Medicare. It's a great benefit for the patient. That's

Speaker 2: 18:45

Like super good news on the payment front for listeners, Medicare Part A, that's the part it's covered on. And that is the one that kind of, everybody has, right?

Speaker 3: 18:54

Medicare Part A covers your hospitalization, that covers hospital , it covers inpatient care. Medicare Part B covers your outpatient visits. Medicare Part D covers your medications. The hospital also covers the medications when you are enrolled, not for the curative intent, but even like, like anxiety or things that provide comfort. So it treats all those symptoms. So

Speaker 2: 19:17

Don't worry folks, if , um, uh, most insurance including Medicare would cover hospice care, that's actually , uh, encouraging news. And Wonderful. Before I let you go, what advice would you give to families out there who maybe haven't considered hospice care for a loved one?

Speaker 3: 19:34

Talk to your physician. Keep the patient's goals and wishes in mind. Research shows that families of hospice patients are more likely the non hospice patients to report that the loved ones had their end of life wishes fulfilled. You know, with a chronic disease, with a natural trajectory of decline, hospital provides that comfort, that dignity, that support to the patient and the family and families who fear giving up. It's more of a shift from focusing on cure to focusing on , um, comfort because you know, at some point your physicians of advice that cure is no longer benefiting the patient . So we wanna support our families to what, what would benefit them

Speaker 2: 20:22

Both Dr. Anwar and I know a guy named Scott Davies, he was my predecessor , uh, a few years ago as the chair of medicine at Hennepin Healthcare. And he always used to say, you know, we're all gonna die. Our job is to help facilitate a good death. And hospice is one way . It's a hopeful way to, to help usher , uh, your loved one through those last stages of their life here. So I actually think hospice is one of the most encouraging, hopeful things that I encounter in healthcare. And so I really appreciate some of those comments. So, beyond our conversation here, Miriam , where might people go to learn more , uh, or get more information?

Speaker 3: 20:56

The National Hospice and Palliative Care Organization and h hpco.org has great information on the website regarding both palliative care and hospice care. So I would really encourage families to go to that website to get more information. I work with Acumen and their website is also great for information regarding Hospice

Speaker 2: 21:17

Acumen is E-C-U-M-E-N listeners

Speaker 3: 21:19

And the Mayo Clinic website. I would also recommend for information,

Speaker 2: 21:23

We have great colleagues with our, our friends down at Mayo. So those are really three great places to go. If you want more information, we will put links to those in our show notes listener so you can get easy access to great information about hospice care. Dr. Mary Manir , thank you for being on the show for enlightening us about hospice care and about the practice of geriatrics medicine. I think you've given hope and information for lots of people. I really appreciate you being on the show.

Speaker 3: 21:50

Thank you for having me. I really enjoy talking with you

Speaker 2: 21:53

Listeners, be sure to tune in later this fall when we will be talking about caring for the elderly with geriatrician Dr. Kerry Sheets . And on our next episode, we're gonna be talking about measles. It's back. And so are we In two weeks, I hope you'll tune in and in the meantime, be healthy and be well.

Speaker 1: 22:10

Thanks for listening to the Healthy Matters podcast with Dr. David Hilden . To find out more about the Healthy Matters podcast or browse the archive, visit healthy matters.org. Got a question or a comment for the show, email us at Healthy matters@hcme.org or call 6 1 2 8 7 3 talk. There's also a link in the show notes. The Healthy Matters Podcast is made possible by Hennepin Healthcare in Minneapolis, Minnesota, and engineered and produced by John Lucas At Highball Executive Producers are Jonathan, CTO and Christine Hill . Please remember, we can only give general medical advice during this program, and every case is unique. We urge you to consult with your physician if you have a more serious or pressing health concern. Until next time, be healthy and be well.