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Hospice female patient being visited at bedside by hospice nurse wearing full PPE (yellow gown, yellow head protection, purple gloves, clear eye goggles, and mask)

Caring for patients in a hospice setting is a nurturing and supportive effort that draws on the expertise of professionals engaged in many disciplines, ranging from medical to therapeutic. Indeed, the services offered by a leading hospice, such as The Connecticut Hospice, may in fact be broader and the care offered patients more varied than what is typically pictured by members of the public.

Even so, hospice-service providers remain concerned about the number of persons accessing hospice care late in the course of an illness. That’s per a new report issued by the National Hospice and Palliative Care Organization (NHPCO), which states that “53.8 percent of Medicare beneficiaries received hospice care for 30 days or less in 2018.”

More telling, is that fully a quarter (27.9 percent) of the beneficiaries received care for seven days or less— which NHPCO considers “too short a period for patients to fully benefit from the person-centered care available from hospice [providers].”

“This annual report provides a valuable snapshot of hospice care access and care, and also a reminder that we must continue to strive to make hospice care more equitable and accessible,” said Edo Banach, NHPCO president and CEO, in a statement. “It is also important to remember that behind these numbers are people who rely on person- and family-centered, interdisciplinary care to help them during a time of great need.”

Of compelling interest to hospice patients and their family members and friends are sections within the full 26-page report on what hospice care entails, how and where that care is delivered to patients, and what are the levels of care provided.

“Hospice focuses on caring, not curing,” NHPCO observes. “Considered the model for quality compassionate care for people facing a life-limiting illness, hospice provides expert medical care, pain management, and emotional and spiritual support expressly tailored to the patient’s needs and wishes. Support is provided to the patient’s family as well.”

The report also points out that, in most cases, “care is provided in the patient’s home but may also be provided in freestanding hospice facilities, hospitals, and nursing homes and other long-term care facilities. Hospice services are available to patients with any terminal illness or of any age, religion, or race.”

What is “hospice?"

several hands supporting a hospice patient's hands that are holding a mound of sand 
and all supported by a white glowing light

Indeed, the term “hospice” is somewhat elastic. It describes any approved provider of hospice services, including those that operate free-standing hospice inpatient hospitals and those that bring hospice care directly to patients where they are, be that a long-term care facility or in their own home.

The Connecticut Hospice (also known as CT Hospice) fits both descriptions, as it operates its own hospice hospital in Branford and fields teams of hospice medical professionals and caregivers to provide services at other caregiving facilities where patients are residing or right in the patients’ homes.

When hospice services are provided as in home, a family member typically serves as the primary caregiver and, when appropriate, helps make decisions for the terminally ill individual, notes NHPCO. “Members of the hospice staff make regular visits to assess the patient and provide additional care or other services. Hospice staff is on-call 24 hours a day, seven days a week. The hospice team develops a care plan that meets each patient’s individual needs for pain management and symptom control.”

An interdisciplinary hospice team usually consists of the patient’s personal physician, hospice physician, nurses, hospice aides, social workers, bereavement counselors, clergy or other spiritual counselors, trained volunteers, and speech, physical, and occupational therapists, if needed.

NHPCO lists these as interdisciplinary team services:

Nancy Peer, an Associate Professor for Hospice and Palliative Care at Central Connecticut State University, secured a bed for her son, Brian, who was dying of testicular cancer, so he could live out his last weeks at CT Hospice. “Every nurse that came in was not only compassionate… they would see how our son was doing and then they wanted to know how they could help us,” Peer recently told the Daily Nutmeg of New Haven.

Peer said that during the week Brian spent at the hospice, before dying at age 39 and leaving behind his wife of one year and his parents and a younger brother, friends and extended family were able to visit him and Peer and her daughter-in-law stayed with him. She remarked that the help he and his family received from CT Hospice was “priceless.”

Levels of hospice care

The NHPCO report also details the four Levels of Care (as defined by the Medicare hospice benefit) that hospice patients may require. The levels are distinguished by the intensities of care provided relative to the course of a given patient’s disease.

“While hospice patients may be admitted at any level of care, changes in their status may require a change in their level of care,” NHPCO explains. “The Medicare Hospice Benefit affords patients four levels of care to meet their clinical needs: Routine Home Care, General Inpatient Care, Continuous Home Care, and Inpatient Respite Care.”

The critical role of volunteers in hospice care

The report rightly credits the significant positive impact of hospice-care volunteers. “The U.S. hospice movement was founded by volunteers” and they “continues to play an important and valuable role in hospice care and operations.”

But volunteering is not a simple matter of stepping up to help others. The Connecticut Hospital, for example, requires that prospective volunteers receive a background check before coming onboard and then they are professionally trained by hospice staff to provide care and assistance to patients and their loved ones.

The importance of volunteers is underscored by NHPCO’s observation that “hospice is unique in that it is the only provider with Medicare Conditions of Participation requiring volunteers to provide at least 5% of total patient care hours.”

Volunteers typically provide service to others in these three general areas:

male volunteer pushing female hospice patient in wheelchair on outside grounds of Ct Hospice in-patient facility located on shoreline with views of blue water and skies.

Spending time with patients and families (“direct support”)

Providing clerical and other services that support patient care and clinical services (“clinical support”)

Engaging in activities such as fundraising, outreach and education or serving on a board of directors (“general support”)

For information on volunteer opportunities with The Connecticut Hospice, please go to our website, www.hospice.com, or contact Joan Cullen at [email protected] or 203-315-7510.

The Connecticut Hospice is America's first hospice. It was founded by Florence Wald, and a group of nurses, doctors, and clergy, in 1974 and was the first of its kind in the United States. A few years prior, Wald, then an Associate Professor and Dean of the Mental Health and Psychiatric Nursing Program at Yale University, was inspired by a palliative care lecture given by Dr. Cicely Saunders, the founder of St. Christopher’s Hospice, the first hospice in the world.

Today, CT Hospice’s services encompass both in-home and inpatient care for persons diagnosed with a terminal illness with a limited prognosis, normally of six months or less.

The Connecticut Hospice’s central commitment is to enable the patient to live as fully and completely as possible during the time of their illness. This includes supporting the entire family as the unit of care, rather than just the patient. For example, home-care programs are designed to make it possible for families to keep the patient at home if such care is appropriate, and to marshal community resources to help deepen support and keep care costs as low as possible.

Yale Hospice & Palliative Medicine Fellows train at Connecticut Hospice

Two doctors face camera with welcoming CEO Barbara Pearce between them

We are delighted that clinical rotations have recommenced at Connecticut Hospice, following a temporary hold forced by COVID-19.  

On July 13 CEO Barbara Pearce and Medical Director Dr. Joseph Sacco welcomed Hospice and Palliative Care Fellows Dr. Alex Choi and Dr. Bryan Terry for orientation prior to their rotations with Connecticut Hospice in partnership with Yale-New Haven Medical Center's Hospice and Palliative Medicine Fellowship Program.

While at Connecticut Hospice, they will spend time Inpatient and in Home Care with the Interdisciplinary Team, and will expand their knowledge and experience in all aspects of hospice and palliative care, including:

Recognized nationally and internationally as a pioneering hospice and palliative care teaching institution through its educational branch, The John D. Thompson Hospice Institute for Education and Learning, Connecticut Hospice is proud to share its expertise with clinicians from around the country and the world.  We look forward to welcoming Dr. Faisal Radwi of Saudi Arabia shortly.

Clinical Rotations resume after COVID-19 halt

Doctor wearing jacket and tie smiles at camera

On June 24, Connecticut Hospice welcomed Dr. Nathan Wood, a Yale Primary Care Internal Medicine Resident, to a 2-week rotation with our Medical Department and the Interdisciplinary Team.  Connecticut Hospice’s care-providers are not only proud to share their hospice and palliative care experience with new healthcare practitioners, but also pleased to receive additional knowledge from visiting practitioners. 

Dr. Wood has published on a variety of topics, including hands-on curriculum for teaching practical nutrition, code-switching in medical settings, and the effects of fibromyalgia on long-term analgesic outcomes following total knee and hip replacement surgery.

Emmy Award-winning Culinary Institute grad

Dr. Wood is also a graduate of the Institute of Culinary Education, where he won the Top Toque Award, presented by faculty for highest academic achievement.  In 2017 and 2018 he worked as a Medical Student Producer for the Dr. Oz Show, and won a Production Award from The National Academy of Television Arts and Sciences Daytime Emmy Awards.  Obviously a man of many talents, our patients and staff have had the pleasure of hearing him play classical piano in our inpatient lobby when not practicing bedside medicine.

Future Hospice and Palliative Care Fellows

This is the first medical rotation since COVID-19 forced a temporary hold on clinical rotations at Connecticut Hospice.  All rotations now include orientation on the correct use of PPE (Personal Protective Equipment) during the coronavirus pandemic.

In July three additional Hospice and Palliative Care Fellows will arrive for orientation prior to each performing a one-month rotation Inpatient and an additional two weeks in Home Care with our teams.  We look forward to welcoming Dr. Faisal Radwi, Dr. Alex Choi, and Dr. Bryan Terry.

Education, Training and Research at Connecticut Hospice

The John D. Thompson Hospice Institute for Education, Training and Research, Inc. (JDT), the educational ally of Connecticut Hospice, was established in 1979 to provide a vehicle for sharing hospice and palliative care philosophy, experience and skills with students, health care professionals, administrators, caregivers, and the community. 

The JDT Hospice Institute offers high-quality continuing education services to physicians and nurses and is accredited to award both CMEs (Continuing Medical Education) and CNEs (Continuing Nursing Education). The Institute is also a premier clinical rotation site and annually host over 300 students from prestigious universities located both in and out of Connecticut and around the world.

To learn more, click here: The John D. Thompson Hospice Institute for Education, Training and Research

 

Pandemic expert Howard Forman in jacket and tie smiling

On June 10, national expert on pandemics and public policy Professor Howard Forman, MD, MBA, FACR, Professor of Radiology and Biomedical Imaging, Public Health (Health Policy), Management, and Economics at Yale University, spoke to Connecticut Hospice staff about COVID-19. 

Professor Forman answered questions on a variety of topics relevant to professional practices and personal lives during the pandemic. 

“It is possible that we are going to live the rest of our lives with a pandemic in some way, shape or form, and we are going to have to acclimate to that.  Think about everything you do, and mitigate the risk as much as possible.  To think we will never go out or attend family functions and gatherings would probably be ridiculous, but we should all avoid crowded, enclosed, indoor spaces or functions".

"Every single thing you do comes with some heightened risk.  The thing that reduces your risk is decreasing mobility and not interacting with anybody and that’s just not how we’re going to be able to live our lives”.

The two practices he emphatically emphasized are wearing a mask always, and testing.

Testing and Spread

“If no vaccine is available I believe that testing is equivalent.  If I could provide you with a $5 - $10 instant test for coronavirus that was highly sensitive, that you could do every day, you would basically eradicate this and have no problem of spread.  And if we did this on a wide scale in the United States for a period of time we would stop this”.

Professor Forman stated the belief that testing will be scaled up and cheap enough for widespread implementation in the next six months.

Ideally, he said, “If you are home with someone vulnerable, test often”. 

On the subject of pre/asymptomatic spread by a COVID-positive person, he confirmed that there is a documented two-day window before symptoms show when you can infect others. 

“It is impossible to know if you are pre-symptomatic.  Your assumption should always be at any given point in time that you might be infected – you just may not have symptoms yet”.

While his warnings are sobering, he concluded that with proper protection – wearing masks, frequent hand-washing, constant adherence to social distancing guidelines and avoiding crowded settings – your risk can be greatly mitigated.

Watch the entire session here:

close-up of aloe plant

Summer is here, and the natural world is exploding with life.  While so many human beings stayed at home this spring, you may imagine what a ‘field day’ plants and animals have had.  Our connection to all things growing is as old as our species, and we reap a myriad of benefits when in touch with nature - rejuvenation, stress-relief, increased health, sustenance, joy, creative inspiration, to name just a few. 

For those unable to get outside because of social isolation or activity-limiting illness, there are many alternative routes to those life-enhancing rewards. 

In this series we will discuss why and how nature is so beneficial to us and we’ll share some resources to help you bring some of the natural world to your own environment, wherever you are.  

In later installments of the series we will visit the world of trees, which we know give us improved health in ways large and small.  Their ability to provide oxygen, shade, medicine, and beauty is unmatched in our planet’s flora.  Later, we’ll journey to the wilderness and find out how the natural landscape can improve our wellbeing and inspire our creativity, even when we are sitting indoors. 

In Part 1 we start closer to home, as we explore gardens, gardening, and the therapeutic role played in our lives by our involvement with plants.

GARDENS

Physical, psychological and spiritual sustenance

Persian floral decoration in green, brown and teal on ancient beige tile
Ancient decorated tile from the Euphraites
Drawing for wild tulip design by William Morris, in yellow, brown and teal on beige paper
Wild tulip, 1884, by William Morris

The human instinct to control our natural environment seems to have existed from our earliest days.  Once we mastered the hunting and growing of ample food supplies, evidence teaches us that our ancestors began to design and plant for pleasure.  Human knowledge of plant life expanded through trial and error to include nutritional, medicinal, and eventually purely aesthetic uses.  When we looked at a beautiful landscape perhaps the pleasure we felt gave us the urge to try to reproduce it.

Six 16th century Turkish glazed blue tiles decorated with flower motifs in white, green and turquoise
16th century Turkish tiles
Detail of a floral design by William Morris in blue, green, white and turquoise
Detail of Wey design by William Morris

For millennia, gardens have been created as places of solace, escape, and relaxation.  They have been catalysts for creativity, inspiring countless works of visual, literary and musical art.  Their design is seeded in the imagination and nurtured by experiment and conditions, the only ‘rules’ being those of climate and space.

Reaping nature’s benefits is accessible to all

Ranging from the most grandiose and formal to a few simple containers on a sunny windowsill, there is a style to please everybody.  Whether private or public, gardens can be manifestations of personal statement and cultural pride. They are sites of solitary, family, or community activity, which know no boundaries of age, geography or wealth.  During times of war and, recently, pandemic, edible produce has been raised in ‘victory’ gardens, allotments, small plots and indoor pots.  Anyone can garden with a minimum of material, (and most gardeners love to share or swap);  very few people are immune to the enjoyment of being in one.

Before we continue, take a moment to enjoy this gallery of plants and gardens, and observe your responses to each of them:

There is a quiet thrill to be found in cultivating a life force other than our own, and wonderful moments of surprise when plants enforce their own will and spring up in unexpected places. As we nurture gardens, so do they nurture us.

Sensory enhancement and better health

Beyond their cultural, historical and social importance, gardens and gardening provide profound physiological benefits. They stimulate all our senses.  One or two plants in an indoor pot can do this, or a richly planted garden outdoors.  We know that aromas can trigger memories, colors can affect our emotions, shape and form feed our ability to use logic and enhance memory.  Likewise, certain natural sounds can reduce our heart rates, and the taste of something healthy and fresh can encourage appetite.  The physical activity of gardening on any level can improve fitness and motor ability.

Colorful vegetable harvest

Gardens and the brain

Because they engage all these senses, it is clear that gardens bring huge rewards.  For persons with cognitive deficits or impaired motor skills, they have a particular value: – the cerebral cortex of the brain, where sensory information is processed, is stimulated by the sights, smells, sounds, tactile textures, and taste of plants and gardens.  The cerebral cortex is also where motor function is controlled and voluntary movement regulated, and it is the area of the brain responsible for processing language, planning and organizing.

The physician and writer, Oliver Sacks, explains the value of gardens:

"As a writer, I find gardens essential to the creative process; as a physician, I take my patients to gardens whenever possible. All of us have had the experience of wandering through a lush garden or a timeless desert, walking by a river or an ocean, or climbing a mountain and finding ourselves simultaneously calmed and reinvigorated, engaged in mind, refreshed in body and spirit. The importance of these physiological states on individual and community health is fundamental and wide-ranging. In forty years of medical practice, I have found only two types of non-pharmaceutical “therapy” to be vitally important for patients with chronic neurological diseases: music and gardens." (from “Why We Need Gardens” in Everything in its Place: First Loves and Last Tales).

Virtual garden tours and garden tutorials

This year more than ever, many of life’s most sustaining activities have by necessity become virtual ones.  While many of us may not be able to travel or experience the beauty of gardens in person, the internet can take us there with a larger number of options and more stunning videography than ever before.

The New York Botanical Garden, a National Historic Landmark and the largest Garden in any city in the United States, is a wonderful source of information, beauty, and escape.  Their website offers marvelous virtual tours through their gardens, ranging from spring flowering bulbs and blossom trees to roses in high summer.  Tutorials by NYBG experts can be found there and on YouTube to help you with indoor plants and outdoor flowers and shrubs.  If you want to grow some of your own fresh vegetables their website also features guides especially tailored for children and beginners.

Click here to tour the gardens or watch their free tutorials:  New York Botanical Garden at home

If you would like to explore some of Great Britain’s famed gardens, including Kew Gardens, National Trust sites and The Royal Horticultural Society’s Chelsea Garden Show, this collection of virtual tours is not to be missed: Enjoy virtual British gardens

Nature’s healing life-cycles

Whether in real life or virtually, the pleasure we can take in gardens and gardening is available to us in every season.  We observe in the life cycles of the natural world an echo of our own finite existence, but there is comfort there in abundance.  The careful preparation of a plant pot or a flower bed, and the expectant anticipation of our success, feed our sense of hope. The excitement of seeing a young shoot first emerge from our soil is hope brought to fruition.

New green shoot

"And don't think the garden loses its ecstasy in winter. It's quiet, but the roots are down there riotous."  - Rumi

Further resources

Click here to read more about the the physical and mental benefits of gardens

To read a recent study comparing the health effects of natural vs city landscape click here: Experimental Study on the Health Benefits of Garden Landscape

To read about gardens in history: 

Ancient Egyptian gardens

Ancient Chinese gardens

Persian gardens

Head shot of Dr. Sten Vermund, Dean of Yale School of Public Health
Dr. Sten Vermund

Sten Vermund, MD, PhD, addresses risk factors of COVID care with Connecticut Hospice staff

Connecticut Hospice was fortunate on the May 27 Town Hall to enjoy the partnership of world-renowned epidemiologist and Dean of the Yale School of Public Health, Sten Vermund, MD, PhD, in educating its staff. 

Dr. Vermund shared his wisdom with Connecticut Hospice staff on COVID-19 protections for health care workers and their families, answering questions on a live Zoom conference, and covering a wide range of topics, including –

With permission from Dr. Vermund, we are pleased to share the entire session with you.  We hope you will find this conversation interesting and informative, and we are sure you will glean some insights and reassurance from his knowledge. 

Read Dr. Vermund’s bio here:

Read more about Dr. Vermund’s work here:

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